Cervical/Lumbar Corrective Patient Information

Cervical/Lumbar Corrective Patient Information

Please complete the information requested to the best of your ability, this will give our Doctors the information they need to best understand your situation.
Patient Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
E-mail Address
Gender
Age
Briefly explain Your problem
When did this first occur?
Who have you seen for this problem?
What treatment have you previously tried?
What were the results?
When were your most current x-rays or MRI’S taken?
What is your current method of treatment?
Any other health problems/concerns?
Major Trauma, Accidents or Falls?
How is this affecting your life?
How did you hear about Dr. Chris Barker?
Intent / Description of Phone Consultation

I understand that this is a phone call consultation only and this is NOT meant to replace a complete examination or evaluation. The intent of this phone consultation is not diagnosis or treat any condition, but merely to review your case and discuss the available options, answer any questions, and the current treatment models. I understand that the doctor doesn't have all data necessary to make a complete diagnosis or prognosis regarding treatment, exams, x-rays and any other testing. I acknowledge that, by preliminarily reviewing any diagnostic imaging or having a pre-treatment consultation to determine whether it is appropriate for NCC to treat you, neither NCC nor Dr.Chris Barker, D.C, are accepting your case for treatment. I agree that my case will be accepted for treatment only if Dr. Barker and NCC provide a written plan agreeing to establish a doctor-patient relationship. Until that time, I agree that no doctor-patient relationship has been established by any preliminary review of any diagnostic imaging or a pre-treatment consultation even if I have been charged fees for such review or consultation. I further agree that the initial review or preliminary consultation with NCC is only for purposes of determining whether your case is appropriate for treatment performed by NCC and Dr. Barker.
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