palmettospinefl.com - Auto Accident Form

Welcomes You
Patient Information
Date:

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Date
Patient:
Patient prefers to be called:
Address:

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Northern Address:

Street Address

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Sex:
Age:
Birthdate:

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Marital Status
Patient SS#:
PRIMARY CARE PHYSICIAN (PCP):
I give you permission to share my health-related information with my PCP listed above.
Phone Numbers
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Format: (000) 000-0000.
Home:
Format: (000) 000-0000.
Work:
Format: (000) 000-0000.
Ext:
Email
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Spouse’s Name:
May we leave medical information on your answering machine or cell phone:
IN CASE OF EMERGENCY, CONTACT:
Name:
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Phone:
Format: (000) 000-0000.
I give your office permission to discuss my medical information with the following individuals:
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Name:
Relationship:
Phone Number:
Format: (000) 000-0000.
Insurance
Primary Insurance Carrier:
Name of Insured (Guarantor):
Guarantor D.O.B.

MonthDayYear
Date
Relationship to Patient:
Insurance ID/CLAIM #
Secondary Insurance Carrier:
Name of Insured (Guarantor):
I Name* , the understand that I am financially responsible for all charges whether or not paid by Insurance and assign directly to Palmetto Spine all insurance benefts, if any, otherwise payable to me for services rendered. I understand that I am fnancially responsible for all charges whether or not paid by Insurance. I hearby authorize the doctor to release all information necessary to secure the payment of benefts. I authorize the use of this signature on all insurance submissions.
Guarantor D.O.B:

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Relationship to Patient:
Insurance Id #
ASSIGNMENT AND RELEASE
Signature
Accident Information
Is condition due to an accident?
Date

MonthDayYear
Date
Type of Accident
To whom have you made a report of your accident?
Attorney Name (If applicable)
Patient Condition
Reason for visit
Mark an X on the picture where you continue to have pain, numbness or tingling.
When did symptoms appear?
Is this condition getting progressively worse?
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)
Type of pain:
How often do you have this pain?
Is it consistent or does it come and go?
When and How did symptoms appear?
Does it interfere with your...
Activities or movements that are painful to perform:
Health History
What treatment have you already received for your condition?

Other
Name and address of other doctor(s) who have treated you for your condition.
Date of Last:
Physical Exam
Dental X-Ray
Chest X-Ray
Blood test
Spinal Exam
Spinal X-Ray
MRI, CT scan, Bone scan
Urine test
Exercise
Work Activity
Habits
Are you pregnant?
Due Date:

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Date
Medications
Allergies
Vitamins, Minerals, Herbs
Injuries / Surgeries
Date

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Date
Description
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
MonthDayYear
Date
Place a mark on “yes” or “no” to indicate if you have had any of the following:

Rows	Yes	No
AIDS/HIV
Alcoholism
Allergy shots
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding disorder
Breast lump
Bronchitis
Bulimia
Cancer
Cataracts
Chemical dependency
Chicken pox
Diabetes

Rows	Yes	No
Emphysema
Epilepsy
Fractures
Glaucoma
Goiter
Gonorrhea
Gout
Heart disease
Hepatitis
Hernia
Herniated disk
Herpes
High cholesterol
Kidney disease
Liver disease
Measles

Rows	Yes	No
Rheumatic fever
Scarlet fever
Stroke
Suicide Attempt
Thyroid problems
Tonsillitis
Tumors/growths
Typhoid fever
Ulcers
Vaginal infection
Venereal disease
Whooping cough

Rows	Yes	No
Migraine headaches
Miscarriage
Mononucleosis
Multiple sclerosis
Mumps
Osteoporosis
Pacemaker
Parkinson’s disease
Pinched nerve
Pneumonia
Polio
Prostate problem
Prosthesis Psychiatric care
Rheumatoid Arthritis

Other

Palmetto Spine
925 10th St E, unit 925
Palmetto, FL 34221
Phone: (941) 212-4410
CONSENT FOR TREATMENT
PATIENT NAME
To the Patient:

Please read this entire document before signing it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

The nature of the chiropractic adjustment:

The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way to move your joints. This may cause an audible “pop” or “click”, as you may
have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis, Examination, Treatment:

As part of the analysis, examination, and treatment, you are consenting to the following

Procedures:
- spinal manipulative therapy
- range of motion testing
- muscle strength testing
- ultrasound
- radiographic studies
- palpation
- orthopedic testing
- postural analysis
- hot/cold therapy
- vital signs
- basic neurological testing
- EMS
- DXD (Ligament Laxity Analysis)
The material risks inherent in chiropractic adjustment:

As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains
and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment.
I will make every reasonable effort during the examination to screen for contradictions to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The probability of those risks occurring

Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for when taking your history, x-rays and performing your examination. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

The availability and nature of other treatment options:

Other treatment options for your condition may include:
- Self administered, over-the-counter analgesics and rest.
- Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers.
- Hospitalization
- Surgery
If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefts of such options and you may wish to discuss these with your primary medical physician.

The risks and dangers attendant in remaining untreated:

Remaining untreated may allow the 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 and less effective the longer it is postponed
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW.
the above explanation of the chiropractic adjustment and related treatment. I have discussed treatment concerns with the Doctors at Palmetto Spine and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. I have been informed of the risks

I hereby give my consent to that treatment.
DATE

MonthDayYear
Date
PATIENT NAME (please print)
PATIENT SIGNATURE
SIGNATURE of PARENT or GUARDIAN (if a minor)

FINANCIAL POLICY
PLEASE READ CAREFULLY

Palmetto Spine will bill a maximum of two insurance carriers on behalf of the patient with the understanding that the final responsibility for payment of the account rests with the patient. Although Palmetto Spine will bill a maximum of two insurance carriers and works closely with the patient regarding the settlement of liability claims, it is done so only as a convenience to the patient in settling his/her account. Palmetto Spine’s filing of the insurance claims on the patient’s behalf does not relieve the patient of the final responsibility for settling his/her account.

Our doctors are Medicare participating.

All payments for deductibles, co-insurance and non-covered services are due at the
time of service.

I completely understand and will comply with the above information.
PATIENT SIGNATURE
DATE

MonthDayYear
Date
WITNESS
DATE

MonthDayYear
Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six (6) years.
PATIENT NAME (PLEASE PRINT)
SIGNATURE
PARENT, GUARDIAN, OR PATIENT’S LEGAL REPRESENTATIVE
DATE

MonthDayYear
Date
THIS FORM WILL BE PLACED IN THE PATIENT’S CHART AND MAINTAINED FOR SIX (6) YEARS.
Should be Empty:

Welcomes You

Patient Information

Phone Numbers

IN CASE OF EMERGENCY, CONTACT:

I give your office permission to discuss my medical information with the following individuals:

Insurance

ASSIGNMENT AND RELEASE

Accident Information

Patient Condition

Health History

Date of Last:

Place a mark on “yes” or “no” to indicate if you have had any of the following:

VEHICLE ACCIDENT INFORMATION

Patient Information

Accident Site

Impact

Other Vehicle

Police

Patient Condition

Patient Treatment

Symptoms/Injuries

If you have had any of the following symptoms since your injury, please check.

I certify that the above information is correct to the best of my knowledge.

CONSENT FOR TREATMENT

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.

FINANCIAL POLICY

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

THIS FORM WILL BE PLACED IN THE PATIENT’S CHART AND MAINTAINED FOR SIX (6) YEARS.