• Child Member Health Record

    Age 0-3

  • ABOUT THE CHILD

  • Format: (000) 000-0000.
  • DATE OF BIRTH
     - -

  • ABOUT THE PARENT

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • INSURED'S DATE OF BIRTH:
     - -

  • VACCINATIONS/MEDICATIONS

  • HAVE YOU CHOSEN TO VACCINATE YOUR CHILD?
  • IF YES, SELECT ALL THAT YOUR CHILD HAS RECEIVED:

  • CHIROPRACTIC EXPERIENCE

  • HAVE YOU SEEN OR HEARD OF OUR OFFICE BECAUSE OF (ALL THAT APPLY):
  • HAVE YOU BEEN ADJUSTED BY A CHIROPRACTOR BEFORE?
  • APPROXIMATE DATE OF LAST VISIT
     - -

  • REASON FOR THIS VISIT

  • DESCRIBE THE REASON FOR THIS VISIT:
  • IS THE PURPOSE OF THIS APPOINTMENT RELATED TO:
  • HAS THIS CONDITION:
  • DOES THIS CONDITION INTERFERE WITH:
  • HAS THIS CONDITION OCCURRED BEFORE?
  • HAVE YOU SEEN OTHER DOCTORS/CHIROPRACTORS FOR THIS CONDITION?

  • PRENATAL HISTORY

  • DURING PREGNANCY DID YOU USE:
  • LOCATION OF BIRTH:
  • DESCRIBE YOUR DELIVERY:
  • DID YOU EXPERIENCE ANY ILLNESS(S) WHILE PREGNANT?

  • APGAR SCORES:

  • ULTRASOUND DURING PREGNANCY?
  • DID YOU BREASTFEED THE BABY?
  • DID YOU FORMULA FEED THE BABY?

  • AT WHAT AGE DID YOU INTRODUCE:

  • ARE YOU AWARE OF ANY FOOD OR JUICE ALLERGIES OR INTOLERANCE?

  • CHILD'S CURRENT HEALTH STATUS

  • HAS YOUR CHILD EVER TAKEN ANTIBIOTICS?
  • HAS YOUR CHILD EVER BEEN HOSPITALIZED?

  • THE NATIONAL SAFETY COUNCIL REPORTS APPROXIMATELY 50% OF CHILDREN FALL HEAD FIRST FROM A HIGH PLACE DURING THEIR FIRST YEAR OF LIFE (I.E.: BED, CHANGING TABLE, STAIRS, ETC.).

  • HAS THIS THE CASE FOR YOUR CHILD?
  • HAS YOUR CHILD EVER BEEN IN A CAR ACCIDENT?
  • HAS YOUR CHILD EVER HAD SURGERY?
  • DOES YOUR CHILD HAVE DIFFICULTY INTERACTING WITH OTHERS?
  • HAVE YOU OR ANYONE ELSE NOTICED THAT YOUR CHILD IS NERVOUS, TWITCHES, SHAKES OR EXHIBITS ROCKING BEHAVIOR?

  • CHILD'S HEALTH HISTORY

  • INSTRUCTIONS: Please check each of the diseases or conditions that the child now or has had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

  • NOTICE OF PRIVACY POLICY

  • 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 changes 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 & 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.
    • Conduct normal healthcare operations such as quality assessments and physician's certifications.

    I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed.

  • DATE:
     - -

  • AUTHORIZATION FOR CARE OF A MINOR

  • It is understood and agreed that the payments to the doctor for x-rays is for examination of x-rays only. The x-ray films 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 in this office. I understand that all services are to be paid in full at the time of service, unless other arrangements have been made and agreed in writing.

    I hereby authorize the doctors in this chiropractic office and whomever they may designate as their assistant to administer chiropractic care, to work with my condition through the use of adjustments and procedures the doctor deems appropriate. I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I agree that I am responsible for all 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 if I suspend or terminate my care for any reason, any fees for professional services rendered me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider for services rendered.

    I authorize the use of this signature to allow the insurance companies to pay Complete Health and Allergy Center directly any amounts payable as my assignment of benefits. I authorize the use of this signature on any insurance submissions.

  • DATE
     - -

  • Consent for Treatment & Use of Records
    I, the undersigned, voluntarily consent to treatment by the practitioners and clinical staff of The Montana Clinic. I understand that, as in the practice of medicine, in the practice of chiropractic care there are some risks to treatment, including and not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of treatment which the doctor feels at the time, based on the facts then known, is in my best interest. I also voluntarily consent to the use and disclosure of my protected health information (PHI) for treatment, payment and operations and such other purposes that are permitted under the federal Health Insurance Portability and Accountability Act (HIPAA) without a written authorization.

    Financial Responsibility
    I accept that I am financially responsible for all services rendered on my behalf for which a charge may be associated. I accept personal responsibility for all co-payments, deductibles, and non-covered services, as dictated by my insurance coverage, plus any collection costs for amounts personally owed by me.

    I acknowledge that not all services provided by The Montana Clinic are covered by my insurance plan for one or more reasons, including but not limited to exclusions from my insurance plan, my insurance plan's designation of The Montana Clinic as an out-of-network provider, and/or my failure to provide my insurance card.

    Authorization
    I authorize payment directly to The Montana Clinic for services for which The Montana Clinic accepts payment. I accept responsibility for all charges if I do not have medical insurance. I have been informed that the services provided may not be covered by my insurance plan. I elect to proceed with service with the understanding that I may be personally responsible to pay for the service being rendered to me.

  • Date
     - -
  • Should be Empty: