Kabir Center for Health - Pediatric History Form (Ages 0-13)

PEDIATRIC HISTORY FORM

PATIENT DEMOGRAPHICS
Today's Date

MonthDayYear
Date
Child's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Birth Height*
Birth Weight*
Current Height*
Current Weight*
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*
Please enter a valid phone number.
Mother's Name*

First NameLast Name
Mother's Mobile Phone Number*
Please enter a valid phone number.
Father's Name*

First NameLast Name
Father's Mobile Phone Number*
Please enter a valid phone number.
Pediatrician/Family MD*
City & State*
Last Visit*

MonthDayYear
Date
Reason for visit
Who is responsible for this bill?*
Mother's Social Security #*
Father's Social Security #*

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.

The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on behalf of. I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor’s discretion.
Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.*

Accept
Signature*

Powered by Jotform SignClear
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.
Child's Name

First NameLast Name
Guardian's Signature

Powered by Jotform SignClear
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 (i.e. parent/guardian’s name, spouse, etc.):
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.
Name of Minor Child*

First NameLast Name
Parent/Guardian Signature*

Powered by Jotform SignClear
Date*

MonthDayYear
Date
Should be Empty:

PEDIATRIC HISTORY FORM

CHILD'S CURRENT PROBLEM

ACTIVITIES OF DAILY LIVING/SYMPTOMS/MEDICATIONS

PHOTO / VIDEO RELEASE

HIPAA CONSENT FORM