Perinatal/ Pregnancy Intake

Perinatal/ Pregnancy Intake

Please call or make an appointment online prior to filling out this form.
Patient Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Preferred name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Estimated Due Date

MonthDayYear
Date
Weeks Pregnant
OB / Midwife Provider & Contact
Emergency Contact Name & Phone
Relation

HIPAA Notice & Acknowledgment
Yor Privacy Rights
We are committed to protecting your health information. Your information may be used for treatment, payment, and healthcare operations as required by law. A copy of our Notice of Privacy Practices is available at the front desk and upon request.
Signature
Date

MonthDayYear
Date

Informed Consent to Chiropractic Care
Chiropractic care focuses on supporting the nervous system and musculoskeletal system so the body can function, adapt, and heal as efficiently as possible. Care is gentle, individualized, and appropriate for each person's age, size, and health history. I understand that chiropractic care does not diagnose or treat disease, that results may vary, and that no guarantees have been made regarding outcomes
Signature
Date

MonthDayYear
Date

Financial Policy & Insurance
Payment is due at the time of service unless prior arrangements are made. Belleair Bluffs Chiropractic accepts some insurance plans. Insurance benefits are verified as a courtesy and are not a guarantee of payment. Patients are responsible for any balance not covered by insurance
Insurance Plan
Leave blank if uninsured
Method of Payment for First Visit
Signature
Type your full name as your signature
Date

MonthDayYear
Date

Communication & Media Consent
Appointment Reminders & Communication
Photo / Video Consent
From time to time, photos or videos may be taken for clinical documentation, education, or marketing purposes. No identifying information will be shared without your explicit permission. Participation is completely voluntary and will not affect your care
Photo/Video Permission
Signature
Type your full name as your Signature
Date

MonthDayYear
Date

HIPAA Notice & Acknowledgment