Form

Form
Welcome to Wellness Spa of Arden

Dr. Jim Donoghue, Doctor of Chiropractic, and our team are pleased to welcome you. Please complete this form prior to your first visit so we can focus on your care from the moment you arrive. All information is kept strictly confidential.
About You
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Street Address
City, State, Zip
Sex
Are you on birth control?
Marital Status
Dominant Hand
Height (Feet, Inches)
Weight
Emergency Contact Name and Phone Number
How did you hear about us?
If referred, please list name of referring person or doctor or describe how you heard about us so we can thank them
Your Health Today
What is your main complaint or all reasons for your visit today?
Pain Scale (please indicate pain levels)

0

1

2

3

4

5

6

7

8

9

10

0 is no pain, 10 is severe pain
How long have you had this condition?
Is this condition getting worse?
Is this condition interfering with?
If other, please describe
What activities or positions make your condition worse?
What activities or positions make your condition better?
Have you had this condition before?
Please describe any previous treatment for this condition and when
List all current medications and supplements
List any recent tests or imaging and results, if known (X-rays, MRI, CT Scan, bloodwork etc.)
List any surgeries or major medical procedures and date, if know
Please list any history of broken bones or fractures and approximate date
Please describe any significant history of trauma, accidents, or injuries and dates
Please list any / all known allergies
Describe your diet
Do you drink or smoke? If yes, please describe your drinking/smoking habits
Please describe your level of exercise or physical activity
Family Health History
Does your immediate family have a history of any of the following
If yes, please describe and indicate relationship (mother, father, sibling etc.)
Name of Primary Care or Personal Physician
Physician Phone Number
Do you consent to us contacting your primary care physician if needed for coordinated care?
Insurance & Financial Information
Type of visit
Insurance Company Name (if applicable)
Policy Number (if applicable)
Name of Insured
Relation to Insured
Insurance Company Phone Number
Where you involved in an auto collision?
If yes, Date of Collision
Name of your attorney (if applicable)
Attorney phone number (if applicable)
Financial Agreement
Financial Policy — Please Read Carefully

Payment for services is due at the time of your visit unless prior arrangements have been made. We accept cash, Visa, and Mastercard.

For auto collision patients, we will bill your auto insurance directly and handle approved appropriate medical liens so you can focus on your recovery.

For private insurance patients, we will make every effort to verify your coverage and bill your insurance in a timely manner. Please note that you are personally responsible for any deductibles, co-pays, and unpaid balances regardless of insurance coverage.

24 hours notice is required if you are unable to keep your appointment. Failure to provide adequate notice may result in a cancellation fee.

If you suspend or terminate care, any outstanding fees for professional services rendered will be immediately due and payable.

If you have any questions about fees or payment options please call us at (916) 333-1166 before your appointment.
I have read and understand the financial policy above
Authorization to Release Medical Records for Billing Purposes
Assignment of Benefits
Consents & Your Rights
HIPAA Notice — Your Privacy Rights

The Wellness Spa of Arden is committed to protecting your private health information (PHI). Your information will only be used to provide treatment, obtain payment, and conduct necessary healthcare operations.

You have the right to:
- Request restrictions on how your information is used
- Receive a copy of our Privacy Notice
- Revoke this consent in writing at any time for future transactions

This consent is valid for 7 years from the date signed. The practice reserves the right to refuse treatment if this consent is not provided.

By signing this form you acknowledge that you have received and understood our HIPAA Privacy Notice.
HIPAA Consent
Informed Consent for Chiropractic Care
THE WELLNESS SPA OF ARDEN INFORMED CONSENT FOR CHIROPRACTIC CARE

To the patient (or their parent, legal guardian, court appointed
conservator, or agent): Please read this entire form prior to
signing it. It is important that you understand the information
contained in this form. Please ask any questions prior to signing
this form if you are unclear about anything in this form.

Chiropractic Adjustments - The primary treatment render by the
Doctor of Chiropractic to you will be chiropractic adjustments,
which are purposely intentioned movements of bones with the desired
effect being to alter nerve/neurological activity, which then allows
your body to use its innate (natural) ability to heal itself. Chiropractic
adjustments also have the desirable effect enabling muscles,
tendons, and ligaments to properly function and heal, and also
allows blood flow to properly occur. Chiropractic adjustments can
be made by either the use of hands or mechanical instruments to
any bone or joint in the body including both spinal and extremity
bones. You may or may not hear an audible sound, which is just gas
being released from the joint space as bones are moved into their
proper positions.

Other Procedures - There are a number of other procedures used by
Doctors of Chiropractic that may be used on you. A physical
examination will be performed to obtain a baseline level of
functioning as well to partially determine an appropriate course
of treatment and associated recommendations. The physical
examination may include posture checks, range of motion testing,
muscle strength testing, various neurological and orthopedic
testing, and other testing. Radiology is the use of x-rays on the
human body and is used to gain an inside perspective of the human
body that cannot be obtained from a physical examination. Treatment
may include chiropractic adjustments, physiotherapy (such as
ultrasound, interferential therapy, massage therapy, traction,
nutritional / rehabilitation / exercise recommendations, etc.).
Additionally, there may referrals to other doctors as necessary,
and their treatment should involve the same informed consent with
disclosure of risks and benefits as is being done here.

Potential Benefits of Chiropractic and Associated Care - The vast
majority of chiropractic patients tend to achieve good to excellent
improvement in their physical conditions with chiropractic care.
Improvement can be measured in many different ways, including
reduction in pain, increased range of motion, less stiffness,
increased athletic performance, and other ways. It must be
remembered that different people get different results, different
people have different pre-existing conditions, and are of different
ages and occupations (with different types of physical stress).
Your situation is unique, and no guarantees are given. You will
have to determine what results you get for yourself and report
them to your Doctor of Chiropractic.

Material Risks Inherent with Chiropractic Adjustments and Other
Treatment - As with any healthcare procedure, there are certain
complications which may arise when chiropractic adjustments and
other care/procedures are performed. These complications include
but are not limited to fractures of bones, disc injuries,
dislocations, muscle strains, cervical myelopathy, strokes,
radiation exposure, costovertebral strains and separations, and
burns. Some patients feel some stiffness and/or soreness following
the first few days of treatment. The physical exam can temporarily
worsen symptoms, but is a necessary part of chiropractic care. The
Doctor of Chiropractic will make every reasonable effort during
the examination to screen for contraindications to care, but
remember it is your responsibility to inform the Doctor of
Chiropractic of any conditions that would not otherwise come to
their attention.

Probability of Risks Occurring - Fractures are rare occurrences
and generally result from some underlying weakness of bone. Even
though a competent history, examination (which may include
radiography) will be performed, it is still possible for some
weaknesses of bone to be undetected. Extremely rare are strokes
from vertebral artery dissection which also occur in about one
person in 133,000 in general (not related to chiropractic), but
are estimated to occur in between one in one million and one in
five million cervical adjustments. Although discs are generally
helped with chiropractic care, they can be worsened even to the
point of requiring surgical care (although this rarely occurs).
Physiotherapy can sometimes burn skin by irritating it,
although this is unlikely to occur.

A perspective on the risks of chiropractic care as compared to
medical care can been seen by the money paid by different doctors
for a $1,000,000 malpractice liability policy. A general medical
doctor pays about $20,000 per year, an internal medicine specialist
pays about $50,000 per year, and medical specialists such as
surgeons, cardiologists, and obstetrics and gynecologists (OBGYN)
pay about $150,000 per year. In stark contrast, Doctors of
Chiropractic in California pay about $3,000 per year. Also, it
has been reported that about 187,000 deaths occur every year from
medical malpractice, but that the number for chiropractic is
typically zero per year.

Consequences of Not Obtaining Chiropractic Care - Not obtaining
chiropractic care will have the effect of not obtaining its
benefits such as having your body function at its best ability,
reducing pain, peak athletic performance, etc. Not obtaining
chiropractic care may allow formation of adhesions and reduce
mobility which may set up a pain reaction further reducing
mobility. Over time this process may complicate treatment making
it more difficult, requiring more time (and money), and less
effective when chiropractic care is obtained later in time. Not
obtaining chiropractic care following trauma such as whiplash or
other effects of automobile accidents will cause injured muscles,
tendons, and ligaments to heal improperly and be significantly
weaker and more prone to re-injury as compared to receiving proper
chiropractic care.

Alternatives to Chiropractic Care - Other treatment options for
your condition may include rest, alternative therapies such as
acupuncture, physical therapy, medical care, medications (both
over the counter and prescribed), hospitalization, and surgery,
and others. If you choose to use other treatment options, you
should discuss the risks and benefits with your medical doctor or
other provider.

DO NOT SIGN THIS FORM UNTIL YOU HAVE READ AND UNDERSTOOD IT.
Signature - Informed Consent
Patient Printed Name
Date of Signature

MonthDayYear
Date
Social Media Consent (Optional)
From time to time we capture photos and videos of our patients for educational purposes and/or promotional content on our social media platforms including TikTok, Instagram, and Facebook. Want to be TikTok famous? 🎬 This is completely optional and has absolutely no effect on your care. But who knows — your recovery story or treatment moment could inspire someone else to finally take care of themselves! You may withdraw consent at any time in writing. No pressure — but we'd love to have you as part of our community!
Social Media Consent
Signature
Date of Signature

MonthDayYear
Date
Stay Connected with The Wellness Spa of Arden
Would you like to receive occasional wellness tips, movement advice, and updates from Dr. Jim and our team? We promise - no spam, just useful content delivered maybe once or twice a month.
Minor/Parental Consent
Is the patient a minor?
Minor's Representative's Full Name

First NameLast Name
Relationship to Minor
Parent / Guardian Phone Number
Parent / Guardian Email
Minor Patient Date of Birth

MonthDayYear
Date
By signing below, the parent or legal guardian authorizes
Dr. Jim Donoghue, D.C. and Wellness Spa of Arden to evaluate
and treat the minor patient named above. The parent or guardian
confirms they have read and understand all consent forms
contained in this document and agree on behalf of the minor.
Parent / Guardian Signature
Date of Signature

MonthDayYear
Date
Final Acknowledgment & Signature
By signing below I confirm that:

- I have read and understood all sections of this intake form
- The information I have provided is accurate and complete
- I consent to evaluation and treatment by Dr. Jim Donoghue,
D.C., and any licensed associates or staff members of Wellness
Spa of Arden including massage therapists, estheticians, and
other wellness practitioners
- I have read and agree to the Financial Agreement
- I have read and agree to the HIPAA Privacy Notice
- I have read and understand the Informed Consent for
Chiropractic Care
- I understand I may ask questions at any time before or
during treatment
- I understand I may withdraw consent at any time in writing

If you are signing on behalf of a minor patient, you confirm
you are the legal parent or guardian and have authority to
consent to treatment on their behalf.

Wellness Spa of Arden
2233 Watt Avenue, Suite 100
Sacramento, CA 95825
(916)333-1166
WellnessSpaOfArden.com
Signature of Patient or Guardian
Printed Name
Date of Signature

MonthDayYear
Date
Should be Empty:

Form

Welcome to Wellness Spa of Arden

About You

Your Health Today

Family Health History

Insurance & Financial Information

Financial Agreement

Consents & Your Rights

Informed Consent for Chiropractic Care

Social Media Consent (Optional)

Stay Connected with The Wellness Spa of Arden

Minor/Parental Consent

Final Acknowledgment & Signature