Pediatric Application For Care

Pediatric Application for Care

Anchor Family Chiropractic-- 55 Freedom Pkwy /Ste 112/ Hoschton, GA 30548
Child's Full Name*

First NameLast Name
Parent/Guardian Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date*

MonthDayYear
Age*
Days (D) Months (M) or Years (Y)
Male/Female
Parent/Guardian Phone Number*

Area CodePhone Number
Who is responsible for this bill?*
What is your relation to the patient?
Pediatrician / Family MD Name
Pediatrician / Family MD Phone Number
Birth Height
Birth Weight
APGAR Score
APGAR Score at 5 Minutes After Birth
How did you hear about us?*

Current PatientProfessional Referral/Doctor, Therapist, etc.Google SearchFacebookOther
Is your child receiving care from any other health professionals?*

YesNo
If yes, please name them and their specialty.
Health History

& Current Complaints
Please mark if your child currently has experienced any of the following now or in the past:
AnxietyDizziness/VertigoHeadacheSinus ProblemsEar InfectionsFaintingBed WettingColicConstipationDiarrheaPoor PostureBack AchesNeck PainDifficulty SleepingSensory Processing Issues
AsthmaUlcersHigh Blood PressurePoor AppetiteBladder ProblemsStomach DisordersFrequent Colds/FluHip PainLeg PainArm PainKnee PainADD/ADHDAutism Spectrum DisorderBehavioral ProblemsGrowing Pains
IF YOUR CHILD HASN'T EXPERIENCED ANY OF THESE AND YOU ARE SEEKING WELLNESS FOR YOUR CHILD, SELECT WELLNESS BELOW.

WELLNESS
Which of the following would best describe your child's birthing process?
Purpose of this visit:

Wellness Check-UpInjury or AccidentSpecific Symptom(s)Other
Purpose of this visit:

Wellness Check-UpInjury or AccidentSpecific Symptom(s)Other
If "Injury/Accident", please explain:
IF YOUR CHILD IS EXPERIENCING SYMPTOMS, ENTER INFORMATION BELOW: (If none, please put n/a)*
What are your primary health concerns for your child?*
Please describe when your child's issues first began and how they've progressed since:*
Have they previously been treated for these conditions? If yes, by whom and when?*
What were the results of past treatment?*
What makes things better? *
Please list anything you have tried at home to improve the problem.
What makes things worse? *
Has your child ever experienced the following:

Sports InjuryCar AccidentMotorized Vehicle Accident (Four Wheeler or Dirt Bike)A Fall (Off of a bed/couch, bike, changing table, etc.)
If yes, describe type of accident and when:
Any bowel/bladder changes since the problem began? If yes, please describe:
Health Goals For Your Child
What are your top 3 health goals for your child?*
Goal #1 (Can be general health goals, OR related to their care here)
Goal #2
Goal #3
What would you like to gain from chiropractic care for your child?

Resolve Existing ConditionOverall Wellness/PreventionOther
Have you or your child ever visited a chiropractor?*

YesNoOther
What is their specialty?

Pain ReliefSportsPhysical Therapy & RehabNutritionalSubluxation-BasedNutritionalFamily Wellness
Pregnancy & Fertility History

Please tell us about your pregnancy.
Any Fertility Challenges?*

YesNo
If yes, please explain.
Did Mother Smoke?*

YesNo
If yes, how many per week?
Did Mother Drink?*

YesNo
If yes, how many per week?
List Any Health Diagnoses or Illnesses Mother Faced During Pregnancy.*
How many ultrasounds did mother have during her pregnancy?*
If more than "standard", please explain why.
AnxietyDizziness/VertigoHeadacheSinus ProblemsEar InfectionsFaintingBed WettingColicConstipationDiarrheaPoor PostureBack AchesNeck PainDifficulty Sleeping
AsthmaUlcersPoor AppetiteHigh Blood PressureBladder ProblemsStomach DisordersFrequent Colds/FluHip PainLeg PainArm PainKnee PainADD/ADHDBehavioral ProblemsGrowing Pains

Mark the correct box for each symptom listed below:

	Never	In the Past	Current
Difficulty breathing
Cancer
Seizures/Epilepsy
Rapid Weight Loss/Gain
Night Sweats

Birth and Developmental History
Child's birth was:

VaginalScheduled C-SectionEmergency C-Section
Birth Provider's Name
Practice Name/Location
Please Select Any Applicable Interventions or Complications:*

BreechManual Assistance By Birth ProviderVacuum ExtractionInduction Medication UsedEpiduralForcepsPain Medication UsedEpisiotomyCord WrappedNone, Natural Birth
Please Describe Any Other Concerns or Notable Remarks About Your Child's Labor and/or Delivery:
Was/Is Child Breastfed?*

YesNo
If yes, How Long?
Describe Any Difficulties with Breastfeeding.
Did Your Child Ever Use Formula?*
If Yes, At What Age?
Did/Does Child Ever Experience:*

ColicRefluxSkin IssuesConstipation (going a whole day without a bowel movement)None of these
If Yes, Please Explain.
Does Child Frequently Arch Their Neck/Back, Feel Stiff or Bang Their Head?*

YesNo
If Yes, Please Explain:
List any known allergies or food intolerances.*
Was the child delayed on any of their milestones to the best of your knowledge?*
Please list the child's hospitalization and surgical history with the year it was performed.*
Have you chosen to vaccinate your child?*

Yes, on the schedule recommended by the pediatrician.Yes, on a delayed schedule.No
If yes, please list any vaccination reactions:
Has your child received any antibiotics?*

YesNo
If yes, how many times and list reason:
Any difficulty with bonding or social development?*

YesNo
If yes, please explain:
Night terrors or difficulty sleeping?*

YesNo
If yes, please explain:
Behavioral, social, or emotional issues?*

YesNo
If yes, please explain:
How many hours per day does your child typically spend watching TV, computer, tablet, or phone?*
How would you describe your child's diet?*

Mostly whole, organic foods.Pretty average.High amount of processed foods.
Are there other health concerns, or is there anything else you'd like us to know about your child?*
ACKNOWLEDGEMENT & CONSENT

I, patient or parent/guardian, have provided accurate and complete information to the best of my knowledge.
Electronically Signed By:*

I understand that I am directly and fully responsible to Anchor Family Chiropractic LLC for all fees associated with chiropractic care my child receives.

The risks associated with exposure to ionization and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on behalf of.
Electronically Signed By:*
Date:
WRITTEN CONSENT FOR A CHILD

I AUTHORIZE DR. KATHERINE GEE AND ANY AND ALL QUALIFIED ANCHOR FAMILY CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES AND RADIOGRAPHIC EVALUATIONS TO MY MINOR/CHILD IF DEEMED NECESSARY. I HEREBY AUTHORIZE DR. KATHERINE GEE AND ASSOCIATE DOCTOR(S) TO RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.

AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY ANCHOR FAMILY CHIROPRACTIC.
Electronically Signed By:*

Terms of Acceptance

In order to provide for the most effective healing environment, most effective application of chiropractic procedures, and the strongest possible doctor-patient relationship, it is our wish to provide each patient with a set of parameters and declarations that will facilitate the goal of optimum health through chiropractic.

To that end, we ask that you acknowledge the following point regarding chiropractic care and the services that are offered through this facility:
- Chiropractic is a very specific science, authorized by law to address spinal health concerns and needs. Chiropractic is a separate and distinct science, art and practice. It is not the practice of medicine.
- Chiropractic seeks to maximize the inherent healing power of the human body by restoring normal nerve functions through the adjustment of spinal subluxation(s). Subluxations are deviations from normal spinal structures and configurations that interfere with normal nerve processes.
- The chiropractic adjustment process, as defined in the law of this jurisdiction, involves the application of a specific directional thrust to a region or regions of the spine with the specific intent of re-positioning misaligned spinal segments. This is a safe, effective procedure applied over one million times each day doctors of chiropractic in the United States alone.
- A thorough chiropractic examination and evaluation is part of the standard chiropractic procedure. The goal of this process is to identify any spinal health problems and chiropractic needs. If during this process, any condition or question outside the scope of chiropractic is identified, you will receive a prompt referral to an appropriate provider or specialist, according to the initial indications of the need.
- Chiropractic does not seek to replace or compete with your medical, dental or other type(s) of health professionals. They retain responsibility for care and management of medical conditions. We do not offer advice regarding treatment prescribed by others.
- Your compliance with care plans, home and self-care, etc., is essential to maximum healing and optimal health though chiropractic
  We invite you to speak frankly to the doctor on any matter related to your care at this facility, its nature, duration, or cost, in what we work to maintain as a supporting, open environment.
By my signature below, I have read and fully understand the above statements.

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my satisfaction. I therefore accept chiropractic care on this basis.
Electronically Signed By:*
Date

INFORMED CONSENT FOR CHIROPRACTIC CARE

CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.

I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.
Electronically Signed By:*
Date

Insurance Policies and Fee Schedule
- Consultation- includes practice member history and chiropractic education. This service is complimentary.
- Assessment (new or established practice member)- includes one or more of the following: thermography, surface electromyography, range of motion, motion and/or static palpation, orthopedic testing, neurological testing, leg check. Up to $200.
- X-rays- Specific x-ray views taken of your spine to determine a misalignment/subluxation of your vertebrae, assess for degenerative changes, and rule out further pathology. These can also be used to indicate progress after period of care. $150 per series.
- Chiropractic Adjustment- The actual re-alignment of the vertebra done by hand or with a chiropractic adjustng instrument. $70.
- Home Care- includes any stretch / exercise program, cervical or lumbar traction that is recommended to be done at home. Up to $200.
Release of Authorization/Assignment of Benefits

I authorize and request payment of insurance benefits directly to Katherine Gee, DC. I agree that this authorization will cover all services rendered until I revoke the authorization. I agree that a photocopy of this form may be used in place of the original. All professional services rendered are charged to the patient. It is customary to pay for services when rendered unless other arrangements have been made in advance. I understand that I am financially responsible for charges not covered by this assignment.
Electronically Signed By:*
Date
PHOTO/VIDEO CONSENT

I hereby grant Anchor Family Chiropractic and its representatives the right to use and reproduce any video footage, audio recordings, and photographs captured during my care for advertising, promotional, educational, and related purposes.

I understand and agree to the following terms:

1. **Authorization:** I grant Anchor Family Chiropractic the non-exclusive, perpetual right to use, reproduce, distribute, and display the aforementioned content in all forms of media, including but not limited to print, television, radio, website, social media, and promotional materials.

2. **Ownership:** I acknowledge that Anchor Family Chiropractic owns all rights, title, and interest in the content captured, and I waive any claims to compensation for its use.

3. **Release:** I release Anchor Family Chiropractic, its employees, agents, contractors, and any third parties acting under its authority, from any liability, claims, or demands arising out of the use of the content, including but not limited to claims for defamation, invasion of privacy, or infringement of rights.

4. **No Compensation:** I understand that I will not receive any compensation, financial or otherwise, for the use of the content.

5. **Model Release:** I authorize Anchor Family Chiropractic to use my likeness, and voice in connection with the content.

6. **Minor Participants:** If the participant is a minor, I am the parent/legal guardian of the minor, and I give my consent for their participation and for the use of their content as described in this release form.

7. **Revocation:** I understand that I can revoke this consent at any time.

I have read and understand the terms outlined in this release form, and I am of legal age and competent to sign this agreement. I have signed this release willingly and voluntarily.

By signing below, I acknowledge that I have obtained the necessary consent from the participant or their parent/legal guardian, if applicable, and agree to abide by the terms outlined in this Photo & Video Release and Consent Form.
Electronically Signed By:
Date

Anchor Family Chiropractic LLC NOTICE OF PRIVACY PRACTICE

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances. If you would like a more detailed explanation, one will be provided to you. In addition, you will find we have placed several copies in report folders labeled ‘HIPAA’ on tables in the reception. Once you have read this notice, please sign the last page, and return only the signature page (page 2) to our front desk receptionist. Keep this page for your records.

PERMITTED DISCLOSURES:
1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating areas mean open discussions. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public health and safety - in order to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government agencies or Law enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or apprize you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.
YOUR RIGHTS:
1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.
COMPLAINTS:

If you wish to make a formal complaint about how we handle your health information, please call Dr. Katie Gee t at (678)-835-9828. If they are unavailable, you may make an appointment with our receptionist to see them within 72 hours or 3 working days. If you are still not satisfied with the manner in which this office handles your complaint, you can submit a formal complaint to

DHHS, Office of Civil Rights

200 Independence Ave. SW

Room 509F HHH Building

Washington DC 20201

I have received a copy of Anchor Family Chiropractic LLC Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information, and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me and several copies kept in the reception area. At this time, I do not have any questions regarding my rights or any of the information I have received.
Electronically Signed By:*
Date:
Should be Empty:

Pediatric Application for Care

Health History

Health Goals For Your Child

Pregnancy & Fertility History

Birth and Developmental History

ACKNOWLEDGEMENT & CONSENT