Peak State Wellness

Peak State Wellness

New Patient Intake Form
Welcome to Peak State Chiropractic and Wellness

Your new patient intake paperwork will consist of four sections. Required sections and questions will have a red asterisk attached. Please answer all questions to the best of your ability. If you have any questions, please ask the front desk or practitioner.
1. Section One will consist of your Patient Demographic Information
2. Section Two will consist of your Patient Health History
3. Section Three will consist of Consent Forms for Treatment in our facility
4. Section Four will consist of Authorizations to Verify Eligibility for Durable Medical Equipment
If you are a Parent or Guardian filling out this form for a minor, please enter your name and relationship below:
First and Last Name & Relationship
SECTION ONE- PATIENT DEMOGRAPHICS
Name *

Last Name First Name
Date of Birth *
MM/DD/YYYY
Sex Assigned At Birth:

Male Female
SSN
XXX-XX-XXXX
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Information

Insurance Carrier

Plan/Policy Name

Member ID Group Number

Insurance Type (EPO, HMO, PPO, Other)
Emergency Contact *

Contact Name (First and Last) Phone Number (XXX-XXX-XXXX)
SECTION TWO- PATIENT HEALTH HISTORY
1. Have you had or do you have any of these symptoms in the last 6 months? (select all that apply) *

Alcoholism Allergies/Asthma Anemia Anxiety Arm Pain/ Numbness Arthritis Back Pain/Stiffness Breast Lumps/Tenderness Bronchitis Bruise Easily Cancer Carpel Tunnel Syndrome Chest Pain/ Conditions Chronic Fatigue Cold Extremities Constipation Depression Diabetes Digestive Issues Dizziness Ear Pain/ Problems Emotional/Mental Issues Frequent Urination Headaches/Migraines Heart Disease Heart Issues Hemmorrhoids Herniated Disc Hip Pain Hot Extremities Irritability/Mood Swings Loss Of Balance Loss of Memory Loss of Smell Loss of Taste Loss of Vision Menstrual Problems Muscle Cramps Neck Pain/ Stiffness Numbness in Arms/Hands Numbness in Feet/Legs Pacemaker Prostate Issues Ringing in Ears Sciatica/Leg Problems Shortness of Breath Shoulder Pain/Stiffness Sinus Problems Sleep Issues/Insomnia Stroke/TIA Swelling in Body Swelling in Joints Touch Sensitive Varicose Veins Weight Problems None Other
2. Have you been treated for any conditions/traumas in the last year? *

No Yes
If Yes, What?
3. Is there a chance you are pregnant? *

No Yes
If Yes, How many weeks?
4. Have you had any diagnostic imaging completed in the last year? (MRI, Ultrasound, Xray) *

No Yes
If Yes, What?
5. What Medications/ Supplements are you currently taking? *
6. Have you EVER broken any bones? *

No Yes
If Yes, What?
7. Have you been hospitalized in the last year? *

No Yes
If Yes, What for?
8. Have you had any surgeries in the last year? *

No Yes
If Yes, What for?
9. Have you had any sprains/strains in the last year? *

No Yes
If Yes, What?
10. Have you EVER been struck unconscious? *

No Yes
If Yes, When?
11. On a scale of 1-10 (1= no pain, 10=intolerable), what is your current pain level? *
12. Do you experience pain everyday? *

No Yes
If Yes, Where?
13. Does your symptoms interfere with daily life? *

No Yes
If Yes, What?
14. Does your pain wake/keep you awake at night? *

No Yes
15. Are your symptoms worse during certain times of day? *

No Yes
If Yes, When? (Morning, Midday, Evening, Sleep)
16. Do changes in the weather affect your symptoms? *

No Yes
17. Do you wear orthotics? *

No Yes
18. What activities aggravate your symptoms? *
19. what activities make your symptoms better? *
20. Do you have a history of heart disease in your family? *

No Yes
By signing this document, I acknowledge my medical history is true to the best of my knowledge. I fully understand that omittance of pertinent medical history may affect my treatment and it is my responsibility to inform the practitioner immediately of any changes in my medical status.

* Signature at bottom of form
SECTION THREE- CONSENT FORMS
Peak State Chiropractic and Wellness
Financial Agreement

Please read this document carefully and do not sign until you have fully read and understand our policies.

Cash: It is our policy that patients with no insurance, those with insurance but do not have coverage or choose to be treated as a ‘cash’ patient will be expected to make payment at the time services are rendered. Payments can be made by cash, check, or credit card.

Insurance: It is our policy that insurance policies need to be verified before treatment. It is the responsibility of the patient to give the required information to staff in order to verify benefits in a timely manner. If benefits are unable to be verified at the time of treatment, the patient will be required to pay the cash rate in office. In the event the patient does have insurance coverage, monies will be refunded and the insurance carrier can then be billed. If your insurance company does not pay within 30 calendar days, the billing will be forwarded directly to the patient. It is our policy that all copay(s) be paid up front and will not be sent as an invoice. The patient also acknowledges that they are responsible for any and all co-insurances that may be sent out after treatment per their policy.

Release of Information: It is our policy that requests from insurance for required medical reports or documentation for treatment and progress are to be fulfilled and are necessary to process some patients claims. By signing below, the patient agrees to authorize the release of medical information requested.

Termination of Care: It is our policy that responsibility of payment for all medical fees incurred is the responsibility of the patient being treated. If care is suspended or terminated at any time, the patient’s portion of all charges for services rendered are immediately due and payable to the office. All services rendered by this office are charged directly to the patient or the person responsible for the patients care, regardless of insurance coverage. Further, this office does not discount or reduce the amount of your balance based upon the termination of that business relationship.

Responsibility of Payment: It is our policy that all services rendered in this office are ultimately the responsibility of the patient being treated or the person legally responsible for them or their treatment. All medical bills for treatment are the responsibility of the patient to pay regardless of insurance reimbursement or any settlement you may or may not receive and are due immediately. Further, this office does not discount or reduce the amount of your balance based upon the reimbursement of insurance or settlement.

Payment Arrangements: It is our policy that any payments not made directly in office at the time of service, will be considered past due and subject to an interest charge of 10% per month of your original past due balance.

By signing this document I acknowledge the financial policy of the office and understand how medical bills for treatment are handled. I fully understand that payment of all medical billing submitted is not contingent on any settlement, judgment, verdict by which I may eventually recover said fees incurred. I fully understand that the patient being treated is responsible for any balances regardless of coverage by an insurance carrier.

*Signature at end of form
Peak State Chiropractic and Wellness

Consent for Physical Therapy, Chiropractic and Massage Therapy Examination and Treatment

Please read this document carefully and do not sign until you have fully read and understand our policies.

Chiropractic: I understand that the purpose of chiropractic care is to treat disease, injury and disability through the means of examination, evaluations, diagnosis, prognosis and rehabilitative procedures which may include but are not limited to manual adjustments, activator and other modalities.

Physical Therapy: I understand that the purpose of physical therapy is to treat disease, injury and disability through means of examination, evaluation, diagnosis, prognosis and rehabilitative procedures which may include but are not limited to, mobilization, massage, exercise, and other physical agents to aid in achieving the maximum potential within the capabilities.

Massage Therapy: If at any time there are changes in the information given, or in my condition, I will notify the therapist and update the form before receiving additional massage. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive massage.

The massage treatment I am requesting is for the purpose(s) of relaxation, stress reduction, relief from muscle tension or spasm, to improve range of motion, circulation, or energy and to receive a positive experience of touch.

I understand the massage therapist does not diagnose or prescribe medical illness, diseases, or other disorders, and that spinal manipulation are not part of massage therapy. I further understand that massage therapy is not a substitute for medical examination or diagnosis, and that I take responsibility for consulting with my physician of any ailment or condition of concern to me.

Unless in an emergency or inclement weather, I acknowledge that If I am unable to keep a scheduled appointment, 24-hour notice is required or I may be charged for the time reserved.

All therapies: I understand that, as in the practice of medicine, in the practice of other clinical therapies there are some risks in treatment. I understand that if I receive treatments the most common risks are temporary aggravation of my conditions or soreness. Rarer risks include but are not limited to: fractures, strokes, sprains, burns, and aggravations of disc injuries.

I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the procedure which the practitioner feels, based on the facts known then, is in my best interest.

If at any time there are changes in the information given, or in my condition, I will notify the therapist and update the form before receiving additional treatment. I have stated all my known medical conditions and have answered all questions honestly. If there is any information not directly requested on this form, which would compromise my ability to safely receive physical therapy I will communicate this to the therapist.

If I experience any pain or discomfort during any treatment, I will immediately communicate that to the practitioner so that treatment can be adjusted accordingly. I understand that my feedback is an essential element in my treatment If at any time I become uncomfortable during the treatment, I may bring that to the attention and request the session be modified, temporarily suspended, or brought to an end. However, I can ask that a session be discontinued at any time, for any reason, and the practitioner will honor that request.

I have read, or have had read to me, the above consent. By signing below, I agree to the above-named procedures. I intend for this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

*Signature at end of form
Peak State Chiropractic and Wellness

Consent for Examination and Treatment

Please read this document carefully and do not sign until you have fully read and understand our policies.

I understand the Peak State Chiropractic and Wellness, Orange County is owned and operated by Dr. Jared Young D.C, is licensed by the city of Fountain Valley, and that I may be examined and treated by a licensed practitioner of chiropractic care, massage therapy, physical therapy or oriental medicine.

I understand Peak State Chiropractic and Wellness, Orange County is a multidisciplinary facility. I acknowledge that during the course of my care I (Or the person named below for whom I am legally responsible) may receive therapy, Ultrasound Diagnostics, MRI, diagnostic Imaging, Acupuncture, Massage Therapy, Physical Therapy and other Oriental Medicine procedures, Ayurvedic procedures or other therapies not listed.

I understand that, as in the practice of medicine, in the practice of other clinical therapies there are some risks in treatment. I understand that if I receive chiropractic treatments the most common risks are temporary aggravation of my conditions or soreness. Rarer risks include but are not limited to: fractures, strokes, sprains, burns, and aggravations of disc injuries.

I understand that if I receive acupuncture or other oriental medicine treatments the risks include but are not limited to: minor bleeding, local bruising, fainting, temporary pain or discomfort, and the possible temporary aggravation of prior existing symptoms. I understand that if I receive Ayurvedic procedures the risks include but are not limited to allergic reactions to supplements.

I understand that results are not guaranteed. I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the procedure which the practitioner feels, based on the facts known then, is in my best interest.

I have read, or have had read to me, the above consent. By signing below, I agree to the above-named procedures. I intend for this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

*Signature at end of form
Peak State Chiropractic and Wellness

HIPPA Patient Consent Form

Please read this document carefully and do not sign until you have fully read and understand our policies.

Our notice of Privacy Practice provides information about how we may use and disclose protected health information about you. This notice contains a Patient Rights Section describing your rights under the law. You have a right to review our notice before signing this consent as terms of our notice may change. IF we change our notice, you may Obtain a revised copy by contacting out office.
You, the patient, have the right to request that we restrict how protected health information about you for treatment and health care operations. You have the right to revoke this consent in writing signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior consent. The practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPPA).

You, the patient understands the following:
1. Protected Health Information may be disclosed or used for treatment, payment or health care operations.
2. The practice has a Notice of Privacy Practices and the patient has the opportunity to review this Notice.
3. The practice reserves the right to change the Notice of Privacy Practices.
4. The patient reserves the right to restrict uses of their information but the practice does not have to agree with those restrictions.
5. The patient may revoke this consent in writing at any time and all future disclosures will then cease.
6. This practice may condition receipt of treatment upon the execution of this consent.
I have read, or have had read to me, the above consent. By signing below, I agree to the above-named procedures. I intend for this consent to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

*Signature at end of form
SECTION FOUR- DURABLE MEDICAL EQUIPMENT
Durable medical equipment is any medical equipment used in the home to aid in a better quality of living. It is a benefit included in most insurances. Your individual policy may have limits to coverage for Durable Medical Equipment (DME), or no coverage at all. In some cases certain Medicare/Medi-cal benefits, that is, whether Medicare/Medical may pay for the item.

You may be eligible for medical devices such as but not limited to posture pumps, posture vests, back, or joint braces, TENS units, etc. Verification is not a guarantee of coverage.

It is our policy to verify your eligiblity for coverage for durable medical equipment if it is deemed medically necessary by your practitioner or doctor. Information such as your Patient Demographics, and Insurance Policy Information will be disclosed to a third party authorized medical device supplier in order to verify your eligilibilty. This verification process is not able to be completed by our office and must be sent to the third part authorized medical device supplier.

If you are eligible and it is deemed medically necessary, your practitioner or doctor will be in contact to get your fitted for your durable medical equipment, explain the benefits, etc.

*Signature at end of form
I have read, or have had read to me, the above patient demographics, patient health history, treament consents and understand my information will be submitted for eligiblity for Durable Medical Equipment.

By signing below, I agree to the above-named procedures and conditions. I intend for these consents to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Signature *

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