Adult New Patient Form

1. Please enter your information.

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. 

I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed.

At Restoring Life Chiropractic we love to document and share special moments in our office. We do this through photography, video, and story telling in order to share testimonies about life and chiropractic with our community so that people may have HOPE for better health and quality of life. Thank you for being a part of our chiropractic community and helping us help others.

I grant to Restoring Life Chiropractic, its representatives and employees the right to take photographs and video of me and my property in connection with chiropractic care. I authorize Restoring Life Chiropractic, its assigns and transferees to copyright, use and publish the same in print and/or electronically.

I agree that Restoring Life Chiropractic may use such photographs and video of me with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.

I hereby authorize the doctors and staff at Restoring Life Chiropractic to treat my condition as deemed appropriate. At Restoring Life Chiropractic, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Restoring Life Chiropractic responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of healthcare delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you.

Patient Consent to X-Ray

I authorize the performance of x-ray examination, which Restoring Life Chiropractic may consider necessary or advisable in the course of my examination and treatment. I understand that an additional fee may apply if my x-rays are sent to a radiologist for review.

X-Ray Consent for Women of Childbearing Age

This is to certify that, to the best of my knowledge, I am not pregnant, and Restoring Life Chiropractic has my permission to perform diagnostic x-ray examination. I have been advised that certain x-ray examinations, particularly those involving the pelvis, can be hazardous to an unborn child.

If under 18, Parent/Guardian's consent/signature required. By signing below, I confirm only that I have read and understood this form.