New Patient Paperwork
This paperwork takes approximately 10-15 minutes.
You will need to finish once you begin.
If patient is under the age of 18, he/she is considered a minor. We cannot treat a minor without a parent or legal guardian present. If parent or legal guardian is not present, the patient will be asked to reschedule.
Be sure to remember your medication list when you arrive for your new patient appointment. We will need the names of the medications, the dosage and how often you take it.
We want you to be informed about the care in which you may receive, including risks and benefits. This information is given so that you may be knowledgeable about your choice to consent to chiropractic care.
Risks & Benefits of Care:
I understand and am informed that in the practice of chiropractic there are some risks to treatment including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. In the majority of cases chiropractic care offers multiple benefits including the relief of neck pain, headaches and low back pain.
Alternative Treatments including risks and benefits:
Alternative treatments include, but may not be limited to, massage therapy, physical therapy, medication, or surgery. The risks involved with these alternative treatments should be discussed with practitioners within the relative field. Chiropractic care offers a non-invasive, natural treatment of vertebral misalignments.
Risks of no treatment at all:
Chiropractic treatment involves the science, philosophy and art of locating and correcting spinal misalignments and as such, is oriented toward improvement of spinal function relative to range of motion, muscular and neurological aspects. There has been no promise, implied or otherwise, of a cure for any symptom, disease or condition as a result of treatment in this clinic. I understand that the chiropractor will use his hands or a mechanical device upon my body to adjust a joint, which may cause an audible “pop” or “click.” It is my intention to rely on the doctor to exercise professional judgment during the course of any procedures, which he feels at the time to be in my best interest. Neither the practice of chiropractic nor medicine is an exact science, but relies upon information related by the patient, information gathered during examination, and the doctor’s interpretation thereof, as well as the doctor’s judgment and expertise in working with like cases.
Check all that apply
*There will be signature pages to be competed in office with these forms.
*A parent or guardian will need to accompany the minor to their first appointment to sign an authorization to treat the minor when unaccompanied. If the minor arrives to their appointment without a parent or legal guardian present, he/she will be unable to be seen by the doctor and will be asked to reschedule.
Would you like to receive your clinical summary after every visit?
The clinical summary is an after-visit summary that provides you with relevant and actionable information and instructions containing your name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that you need to schedule with contact information, and recommended patient decision aids.
· I acknowledge that I have the right to request a copy of Landers Family Chiropractic’s Notice of Privacy Practices Policy. I consent to the use and disclosure of my protected health information as specified in Landers Family Chiropractic’s Notice of Privacy Practices Policy.
· I understand that in the event I miss an appointment I give consent to Landers Family Chiropractic to send me a postcard regarding that appointment. I understand that I can request in writing an alternate form of communication.
· I understand that my records (including x-rays) are the property of Landers Family Chiropractic and if at any time I request a copy of my records there will be an additional charge for copying them (including x-rays).
· By supplying my home phone number, mobile number, email address, and any other personal contact information, I authorize my heath care provider to employ a third-party automated outreach and messaging system to use my personal information, the name of my care provider, the time and place of my scheduled appointment(s), and other limited information, for the purpose of notifying me of a pending appointment, a missed appointment, overdue wellness exam, balances due, lab results, or other communications. I also authorize my health care provider to disclose to third-parties, who may intercept these messages, limited protected health information (PHI) regarding my healthcare events.