mommaschiro.com-Pediatric Intake Form

PEDIATRIC INTAKE & HISTORY
PATIENT INFORMATION
Patient Name

First NameMiddle NameLast Name
Address
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Email
example@example.com
Sex

MaleFemale
Age
Birthday

MonthDayYear
Parent/Guardian 1's Name
Parent/Guardian 1's occupation
Parent/Guardian 1's Phone
Please enter a valid phone number.
Parent/Guardian 1's Email
example@example.com
Parent/Guardian 1's Relationship To Child
Parent/Guardian 2's Name
Parent/Guardian 2's occupation
Parent/Guardian 2's Phone
Please enter a valid phone number.
Parent/Guardian 2's Email
example@example.com
Parent/Guardian 2's Relationship To Child
IN CASE OF EMERGENCY CONTACT
Name

First NameLast Name
Relationship
Contact Number
Please enter a valid phone number.
Who may we thank for referring you?
HOW CAN WE HELP YOUR CHILD?
Wellness CheckupOther
If your child is already experiencing a symptom, please describe it:
Has your child been treated on an emergency basis?

YesNo
Please describe:
PREGNANCY HISTORY
Did you experience any complications during your pregnancy? (check all that apply)

Back/Other PainGestational DiabetesPre/EclampsiaStrep BNausea/vomitingPre-TermFatigueSwellingOther(please describe)
BIRTH HISTORY
Type of birth (check all that apply):

HospitalBirth CenterHomeNormal / VaginalBreechCesareanScheduled/InducedEpidural
Problems during labor / delivery?
AntibioticsCongenital AnomaliesFailure to ThriveJaundiceMeconiumRespiratory DistressExtended HospitalizationOther
GROWTH & DEVELOPMENT
Infant feeding:

BreastBottleFormula
Number of hours of sleep each night:
Quality of sleep:
At what age did the child:
Respond to sound:
Crawl:
Hold head up:
Stand:
Sit unsupported:
Walk unsupported:
CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS
Has your child had (check all that apply)?

Chicken PoxMumpsMeaslesRubellaRubeolaPertussis/Whooping Cough
Has your child ever suffered from (check all that apply)?:

AllergiesAnemiaArm ProblemsAsthmaBack AchesBed WettingBehavioral ProblemsBroken BonesChronic Ear AchesColds/FluColicConvulsions/SeizuresDelayed SpeechDiabetesDizzinessFaintingHeadachesHeart TroubleHyperactivityHypertensionJuvenile Rheumatroid ArthritisJoint ProblemsLeg ProblemsNeck ProblemsNeuritisOrthopedic ProblemsParalysisPoor AppetiteRuptures/HerniasSinus TroubleTuberculosisWalking ProblemsDigestive Issues(constipation/diarrhea)
Have you vaccinated your child?

NoYesAs scheduledDelayed Schedule
ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY

	ALLERGIES (list)	MEDICATIONS (list)	SURGERIES (list)	FAMILY HISTORY (list)

SIBLINGS
How many children do you have?
Children Ages:
Childrens’ health concerns:Children’s’ Ages:
Number of pregnancies:
Are you currently pregnant?

No
Health concerns regarding this pregnancy?
Authorization for Care of Minor

I hereby authorize this clinic and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward
Signed

Clear
Witnessed:
Date

MonthDayYear
Date
Doctor-Patient Relationship in Chiropractic Informed Consent

It is important to acknowledge the difference between health care specialties of
Chiropractic, Osteopathy & Medicine. Chiropractic health care seeks to restore health
through natural means without the use of medicine or surgery. The success of the
Chiropractic Doctor’s procedures often depends on environment, underlying causes,
physical & spinal conditions & patient compliance on recommendations given by the
Doctor.

Doctors of Chiropractic specialize in biomechanical functions of the body. Every
patient should be mindful of his/her own symptoms & should secure other opinions if
he/she any concern as to the nature of his/her total condition.

A patient in coming to the Doctor of Chiropractic gives the Doctor permission &
authority to care for the patient in accordance with chiropractic tests, diagnosis &
analysis. The chiropractic adjustment or other clinical procedures are usually very
beneficial in treating the patient’s condition as it relates to chiropractic care. In
extremely rare cases, underlying physical defects, deformities or pathologies may
render the patient susceptible to injury.

Should you have any questions or concerns, please speak to the Doctor before signing this consent form.

Momma’s Chiro Consent to Use or Disclose Health Information

I, authorize Momma’s Chiro, to use and disclose my medical information for the
purposes of Treatment, Payment & Health Care Operations:

*Treatment includes, activities performed by a healthcare provider, nurse, office
Staff and other type of healthcare professionals providing care to you, coordination
or managing your care with parties, consultation with and between other healthcare providers.

* Health care operations include the necessary administrative & business
functions.

You may review Momma’s Chiro “Notice of Privacy Practices” for additional information about the uses & disclosures of information described in this consent prior to signing. If you do not wish to receive a copy of our Privacy Notice, please

Because we have reserved the right to change our privacy practices in accordance
with the law, the terms contained in the notice may change also.

You have the right to revoke this consent, in writing, at any time; however, your
decision to revoke the authorization will not affect or undo any use or disclosed
information that occurred before your notification.

MOMMA’S CHIRO FINANCIAL POLICY

Momma’s Chiro may make payment plan arrangements on an individual basis. Any
such plan or arrangement will be discussed during your report of findings.

We accept a fee for service; you are responsible for your entire bill should your
insurance company not pay any of the anticipated charges for any reason. You are
responsible to file your superbill directly to your insurance and get reimbursed directly from your insurance company. Any services not covered by your insurance will be the patient’s responsibility.

We will not enter into any dispute with your insurance company. If coverage problems arise, you will be expected to assist directly in dealing with your insurance company, adjuster or agent. Any denied or disputed claims will be treated as uncovered services and you will be expected to pay such charges on a timely basis. Superbill will be provided by the doctor within the month to the patient.
If you have questions concerning this or any other matter, please speak with the Doctor prior to your appointment.
Signature (Initial) I have read and understand the Financial Policy and agree to abide by these terms.
Momma’s Chiro Cancellation/No-Show/Timeliness Policy

All appointments that are missed or that are cancelled without proper notification as
outlined below are subject to a no-show/cancellation fee.

We request that you provide us with no less than a 24-hour notice when cancelling or
rescheduling a standard office visit. If your appointment is not cancelled within 24-
hours of the appointment time and you are unable to make it in for the scheduled time, it will be considered a missed appointment and is subject to the fee.

Office visits- $25
We request that you provide us with at least 24-hours notice when cancelling or
rescheduling any type of re-exam or x-ray review.

Timeliness
If you fail to arrive at your appointment on time and, consequently, the Doctor is
unable to see you, this will be considered a missed appointment and is subject to the corresponding fee of $90 or $25, depending on the nature of the appointment.

By signing below, I acknowledge that I have read and understand the entirety of thispolicy as outlined above.
Signature

Clear
Date

MonthDayYear
Date
PATIENT VIDEO/PICTURE RELEASE FORM

Authorization and Release of Testimonial Information
I understand my video and/or any picture(s) testimonial (the “Testimonial”) made on behalf of HB Chiropractic/Mommas Chiro (hereinafter called “The Practice”) may be used in connection with publicizing and promoting The Practice. I authorize The Practice to use my name, brief biographical information, and the Testimonial as defined on this form.

I hereby irrevocably authorize The Practice to copy, exhibit, publish or distribute the Testimonial for purposes of publicizing The Practice’s services or for any other lawful purpose. These statements may be used in printed publications, multimedia presentations (i.e. Instagram , YouTube and Tiktok), on websites or in any other distribution media. I agree that I will make no monetary or other claim against The Practice for the use of the statement.

In addition, I waive any right to inspect or approve the finished product, including written copy, wherein my testimonial appears.

I hereby hold harmless and release The Practice from all claims, demands and causes of action which I, my heirs, representatives, executors, administrators or any other persons acting on my behalf or on behalf of my estate have or may have by reason of this authorization.

Full Name:   First Name   Last Name

Signature:   Signature   Date:     Date
Chiropractic Consent Form

HIPAA
The undersigned does hereby acknowledge that he/she has received a copy of this office's Notice of Privacy Practices Pursuant To HIPAA and has been advised that a full copy of this office's HIPAA Compliance Manual is available upon request.

The undersigned does hereby consent to the use of his/her health information in a manner consistent with the Notice of Privacy Practices Pursuant to

I attest that the information on this form, and those preceding, is true and accurate to the best of my knowledge.

Printed Name of Patient:   Type a label

Signature of Patient:   Signature
Date:   Date

Signature of Representative (if patient is a minor or has disability)   Signature
Date:   Date
Should be Empty:

PEDIATRIC INTAKE & HISTORY

HOW CAN WE HELP YOUR CHILD?

PREGNANCY HISTORY

BIRTH HISTORY

GROWTH & DEVELOPMENT

At what age did the child:

CHILDHOOD DISEASES, ILLNESSES & VACCINATIONS

ALLERGIES, MEDICATIONS, SURGERIES & FAMILY HISTORY

SIBLINGS