• Requested Appointment Time

  • New Patient Health History

  • Today's Date*
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  • Patient Birth Date*
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  • Contact Info

  • Format: (000) 000-0000.
  • Marital Status
  • Work Status

  • Experience

  • Have you ever been to a chiropractor before?*

  • Personal Injury

  • Are you coming in because you were in a motor vehicle accident?*
  • Date of the accident*
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  • Did you lose consciousness?
  • Did you go to the hospital?*

  • Your Vehicle Insurance Info

    MedPay is an optional addition to the regular coverage on your policy. It covers your medical expenses and does not affect your deducible nor raise your premium.
  • Do you have MedPay (Medical Payments) on your policy?*
  • Was anyone ticketed?*

  • 3rd Party's Insurance Info

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  • Insurance

  • Do you have health insurance?*
  • Insurance Carrier*
  • Subscriber Birth Date*
     - -
  • Format: (000) 000-0000.

  • Please Select Your Health Concerns Below

  • Select All That Apply*

  • Health History

  • Do you exercise?

  • Blank fields will be assumed to be "none"

  • The next sections have to do with consent to care. Please read these sections prior signing. It is important you understand the information explained. Reach out to our team ask questions before you sign if there is anything that is unclear.

  • Privacy and Sharing of Information
    I authorize True Flow Chiropractic and its official partnership with BackSmith Chiropractic, and its affiliated health professionals to collect and maintain my personal and medical information for the purpose of providing healthcare services. I consent to communication between True Flow/Backsmith and my family doctor, referring physician, imaging center(s), insurance carrier, and/or attorney as necessary for my care.

    I acknowledge that my personal and medical information is confidential and will not be disclosed to third parties without my explicit permission, except when required by law or for essential aspects of treatment, payment, or healthcare operations. I maintain the right to restrict or revoke this permission at any time.

    By signing this authorization, I understand the importance of safeguarding my information and agree to True Flow/ BackSmith Chiropractic’s privacy practices, ensuring the confidentiality and security of my data.

  • Insurance
    I authorize True Flow Chiropractic and its partnership with BackSmith Chiropractic to file insurance claims on my behalf.

  • Examination and Treatment
    I hereby provide my consent for examination and chiropractic care at True Flow Chiropractic/BackSmith and understand that I am responsible for any charges incurred as a result. I acknowledge that I have the right to discontinue receiving further care at any point and that this decision will not impact my initial or ongoing responsibilities for the charges accrued up to that point.

    I also understand that it is my responsibility to provide accurate and complete information regarding my medical history, current health status, and any changes that may affect my treatment. I acknowledge that the information I provide will be used to facilitate my care and treatment at this clinic.

    By signing this consent, I confirm that I am aware there is an inherent risk with all medical/chiropractic services, have been given the opportunity to ask questions, and have had any concerns addressed to my satisfaction.

  • Voice-to-Text & HIPAA
    I, understand True Flow and BackSmith Chiropractic uses audio devices during my visit(s) for the purpose of creating accurate and comprehensive medical records. Information is dictated and transcribed to text; no audio recordings are kept.
    I understand that:
    Purpose: The audio will be used solely for generating a narrative in my medical record, to enhance the efficiency and accuracy of documentation.
    HIPAA Compliance: The use of Voice-to-Chart technology in Jane EHR is designed to comply with the Health Insurance Portability and Accountability Act (HIPAA), ensuring that my protected health information (PHI) is handled securely.
    Confidentiality: All information will be subject to strict confidentiality. See Section 1 (Privacy and Sharing of Information) above.
    Transcription and Deletion: The audio will be transcribed into text for the chart. No audio files are retained.
    Access: I may request access to my transcribed chart notes for review or amendment purposes. However, direct access to the audio recordings will not be available due to their immediate deletion after transcription.

  • 🚨Very Important‼️🚨

     

    Clicking the Submit button below will send your form to our team. We will send a confirmation e-mail and/or text within 24 hours to confirm your requested appointment time if the team has not already added you to our schedule. If you need to reach the office urgently, call 770-343-4128. 

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