Aperta Health intake

GENERAL INFORMATION (Items with a red star are Required for submission)

First name*

Middle

Last*

Preferred Name

Age

Height

Weight

Address (City, State, ZIP)*

Phone*

Email

example@example.com

Occupation (Job Title)

Emergency Contact

Emergency Contact Phone

Emergency Contact's relationship to you

City

Referring Provider

Other

How did you hear about us?

If patient is under the age of 18:

Guardian Name

Phone

Address

Phone

Email

example@example.com

Please circle with your finger where your pain is. (you may circle more than one area)

If pain is associated with your condition, please list all that apply: (Dull Sharp Throbbing Numbness Shooting Aching Stiffness Tingling Cramps Swelling, other)

Explain the location of your pain and describe the issue.

Does the problem interfere with daily functions?

If Yes please explain

Is this condition getting better, worse, or about the same?

Where and when indicated that I may benefit from the services of Aperta Health and it's affiliate facilities. I hereby request and consent to the performance of chiropractic adjustments, muscle therapies and other usual and customary therapy procedures. This may include examination tests, and other physical therapy techniques, on me (or on the patient named below for which I am legally responsible) recommended by providers and assistants of Aperta Health (Chiro Shack) who render treatment or recommendations to me. I understand that, as with any health care procedures, there are certain complications that may arise during a functional health visit, chiropractic adjustment, or therapy session. The clinical procedures performed are usually beneficial to the patient and seldom cause any problem. In rare cases the following may occur, but are not limited to; fractures, disc injuries, bruising, tenderness from treatment, rare reactions from taping, sprain / strains, and discomfort from procedures. I have relayed all pertinent health information to the best of my knowledge and I do not expect the providers to be able to anticipate all risks and complications. I wish to rely on the staff's expertise and exercise judgment during the course of the procedures at the time and based upon the facts then known, and in my best interest. I will assume all responsibility / liability if I withhold or do not report on the health forms any past medical history, illnesses, medications, or allergies. I understand I will have an opportunity to ask questions and discuss with the providers of Aperta Health and/or with office personnel about the nature, purpose and risks and other recommended procedures. I understand that in the process of receiving treatment, as with any health procedure, there is no guarantee of results. I understand that herbal therapy involves recommendations and is not medical care and does not make medical diagnoses. If seeking herbal or essential oil recommnedations, herbalists at Aperta Health are not trained as an MD, DO, or another medical provider. Herbalism in the United States is not a licensed profession. I have read (or have had read to me) the above informed consent. By signing below, I state that I have weighed the risks involved in the potential treatment[s] and have decided that it is in my best interest to undergo treatment recommended and hereby give my consent to said treatment. I intend this consent form to cover the entire course of treatment for my (or the patient whom I am legally responsible for) present condition and for any future conditions for which I may seek treatment.

Do not sign until you have read and understood the above information.

Patient or Legal Guardian Signature Date*

Patient Name*

Print Name

We provide wellness and maintainence chiropractic services. If you need more managed care for your health problem, please make us aware so that we can refer you to a more approprate provider. Our goal is to have chiropractic care available to make functional improvement in our patients and their families. We believe the body when functioning on a higher level, promotes its own healing process at a greater rate.

In addition to chiropractic, we offer supportive therapies to help provide more balance in your body. Light therapies, essential oils, herbs & nutrition, and muscle releases; can all help you gain more benefit from your care.

I have read and fully understand the above statements. All questions concerning the office (Patient Printed Name) objectives pertaining to the care I need have been answered to my satisfaction. I therefore accept care at this location and will make any objections known to the staff.

Name*

Print Name

Patient Signature Date*

CONSENT TO EVALUATE AND TREAT A MINOR CHILD

Parent or Legal Guardian

Print Name

Child's or Ward's Name

Print Name

have read and fully understand

(Child's or Ward's Name) (Parent or Legal Guardian) the terms of acceptance and hereby grant permission for my child / ward to receive care at Balanced Health.

Parent or Legal Guardian Signature Date

APERTA HEALTH INTAKE

INFORMED CONSENT

EXPLANATION OF SERVICES