Kabir Center for Health - New Patient (Ages 14 & Up)

WELCOME TO OUR OFFICE!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.
ABOUT THIS PATIENT
Name*

First NameLast Name
Birthday*

MonthDayYear
Date
Social Security #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
Email*
example@example.com
Gender*

MaleFemaleOther
Marital Status*

MarriedSingle

ABOUT THE SPOUSE
Name

First NameLast Name
Cell Phone
Please enter a valid phone number.

EMPLOYER INFORMATION
Employer
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Type of Work

EXPERIENCE WITH CHIROPRACTIC
How were you referred to our office?*
Have you been adjusted by a chiropractor before?*

YesNo
Reason for those visits?
Doctor's Name
Approximate date of last visit?
Has any adult in your family seen a Chiropractor?*

YesNo
Has any child in your family seen a Chiropractor?*

YesNo

AWARENESS OF CHIROPRACTIC PRINCIPLES

WERE YOU AWARE THAT...
Doctors of Chiropractic work with the nervous system?*

YesNo
The nervous system controls all bodily functions and systems?*

YesNo
Chiropractic is the largest natural healing profession in the world?*

YesNo
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*

YesNo

AUTHORIZATION FOR CARE

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.
Patient's Signature*

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Date

MonthDayYear
Date
Guardian or Spouse's Signature

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Date

MonthDayYear
Date
Who should receive bills for payment on your account?*

PatientSpouseParentWorkers CompMedicarePersonal Health InsuranceAuto Insurance
OWNERSHIP OF X-RAY FILMS

It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

EMERGENCY CONTACT
Name*

First NameLast Name
Relationship*
Work Phone*
Please enter a valid phone number.
Home Phone*
Please enter a valid phone number.

MISSED APPOINTMENTS
We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.
- Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
- With the exception of emergencies, it is vital that you keep all your appointments. Reminder texts will be sent to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
- In the instance of a no show without notice by phone we reserve the right to charge you a $20.00 fee.
- We ask for cancellations and rescheduling appointments that you
  provide 24-48 hours notice in order for us to contact patients on our
  waitlist.
Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.
Patient's Signature*

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Date

MonthDayYear
Date

AGREEMENT

My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit. I have read and agree to the above statement.
Signature*

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Date

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com

PHOTO / VIDEO RELEASE
I hereby authorize Kabir Center for Health and/or other brands owned by Kabir Center for Health, to use my thoughts, comments, experiences, testimonial, treatment, or story for use in image, video, or still. I understand that my image may be edited, copied, exhibited, published or presented in presentation under any legal condition, including but not limited to: marketing, illustration, medical, scientific publication, social media, and web content. In addition, I understand that this material may be used within an unrestricted geographic area.

I agree that there will be no direct payment, royalties or other compensation offered to me by the company arising or related to the use of my image or recording.

I understand that I may revoke this photo/video release at any time by notifying Kabir Center for Health in writing within 48 hours of capture. The revocation will not affect any actions taken before the receipt of this written notification. Images/videos will be stored in a secure location and only authorized staff will have access to them. They will be kept as long as they are relevant and after that time destroyed or archived.

By signing this release, I acknowledge that I have completely read and fully understand the above consent for procedure and image release and agree to be bound thereby. I hereby release any claims against any person or company utilizing this material in compliance with the aforementioned restrictions.
Signature*

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Child's Name (if applies)

First NameLast Name
Guardian Signature (if applies)

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HIPAA CONSENT FORM
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPPA NOTICE that is available to you at the front desk before signing this consent.

1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.

2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.

3. A patient’s written consent need only be obtained one time for all subsequent care given the patient in this office.

4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of these records for the care given proper to the written request to revoke consent but would apply to any care given after the request has been presented.

5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

6. Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.

7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

I give permission to the following individuals to have information regarding my medical condition or billing and insurance information
Name*

First NameLast Name
Relationship*
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
Signature*

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Date*

MonthDayYear
Date
Name*

First NameLast Name
Email*
example@example.com
Should be Empty:

WELCOME TO OUR OFFICE!

ABOUT THIS PATIENT

ABOUT THE SPOUSE

EMPLOYER INFORMATION

REASON FOR THIS VISIT

EXPERIENCE WITH CHIROPRACTIC

AWARENESS OF CHIROPRACTIC PRINCIPLES

GOALS FOR MY CARE

HEALTH HABITS

HEALTH CONDITIONS

FOR WOMEN ONLY:

AUTHORIZATION FOR CARE

OWNERSHIP OF X-RAY FILMS

EMERGENCY CONTACT

NUTRITION AND SELF-CARE ARE JUST TWO OF THE COMPONENTS IN OBTAINING OPTIMAL WELLNESS.

INITIAL CONSULTATION FORM

MISSED APPOINTMENTS

AGREEMENT

PHOTO / VIDEO RELEASE

HIPAA CONSENT FORM