Network Family Wellness Center NP file Adult

Parental Consent Form
I,*
type your name
being the:*

parentlegal guardian
of*
type the child name
do hereby grant permission for him/her to receive care from the Doctors of Chiropractic at Network Wellness Center. This would include, when necessary, standard spinal analysis, appropriate assessment procedures and spinal adjustments.
Parent or Legal Guardian Signature*

Clear
Date

MonthDayYear
Date

CHILD NEW PATIENT APPLICATION

WELCOME TO OUR OFFICE. WE THANK YOU FOR YOUR TRUST!

(Please fill the form. If there is something that does not apply to you please put N/A in the box)
Appt. Date

MonthDayYear
Date
Referred by:
Patient Name*

Child First NameChild Middle NameChild Last Name
Preferred Name:
MaleFemale
Date of Birth*

MonthDayYear
Date
Age
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone *

Area CodePhone Number
Carrier
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Social Security Number
Occupation
Email*
example@example.com
Emergency Contact*
Relationship
Phone #*

Area CodePhone Number
To conserve resources, we generally utilize Email and text for regular communication.
May we communicate with you via Email?

YesNo
Text?

YesNo

Please write down some of the falls, injuries, & traumas that your child has experienced. (Please put N/A if it doesn’t apply to your child)
A. Car Accidents (List even minor ones. A 5 mph crash from a 3000 lb vehicle can cause damage to your child spine even if your child didn’t feel injured!)
Example: 12-1-2007 Type of Collision: Front end 10 mph Injuries: Neck Whiplash/Neck on Rt. side*
B. Sports Injuries (if there are too many to list please write the name of the sport and “MANY” next to it.)
Example: 1-1-2008 Type of Sport: Basketball Type of Injury: Sprained Right Knee *
C. Slip, falls, & Bike Accidents (We understand there may have been a lot of slips & falls since birth, so please list the major ones.)
Example: 2-1-2008 Type of Injury: Slipped on ice & bruised Left Elbow*
PLEASE MARK the areas on the Diagram with the following letters to describe your child symptoms: R = Radiating B = Burning D = Dull A = Aching N = Numbness S = Sharp/ Stabbing T= Tingling
My child is not experiencing any of the above symptoms
The above information is true and accurate to the best of my knowledge. Copies of any x-rays and reports will be released upon written request, however original x-rays remain the property of the clinic. I have been informed evaluation is not for neuromusculoskeletal conditions or evaluation of presenting complaints but for spinal and neurological functional capacity, spinal alignment and presence of spinal subluxation. Procedures recorded represent the limited evaluation procedures chosen to assess this particular patient. Appropriate informed consent documents have been signed to proceed.
Patient/Guardian’s Signature: *

Clear
Date

MonthDayYear
Date
Patient Name: {yourName} - DOB: {dateOf}

Using the codes listed below, please fill in EVERY blank with the applicable letter.

Check to indicate if your child has Pain or Stiffness and on which side of your child body.

If both sides apply, please check R & L.

P = Past Health Issue     C = Current Health Issue     N = Never had this Health Condition
EXTREMITIES*
*
*
*
*
*
*
*
SPINE*
*
*
*
*
Pain with cough, sneeze, or strain with bowel movement LOCATION of Pain:
Other

NUMBNESS/TINGLING OF PAIN IN *
*
*
*
RESPIRATORY*
DIGESTION*
IMMUNE SYSTEM*
Other
ORGAN PROBLEMS OR DYSFUNCTION*

OTHER CONDITIONS*
Other
URINARY TRACT*
Other

MALE*
FEMALE*
Social History*
The above information is true and accurate to the best of my knowledge. Copies of any x-rays and reports will be released upon written request, however original x-rays remain the property of the clinic. I have been informed evaluation is not for neuromusculoskeletal conditions or evaluation of presenting complaints but for spinal and neurological functional capacity, spinal alignment and presence of spinal subluxation. Procedures recorded represent the limited evaluation procedures chosen to assess this particular patient. Appropriate informed consent documents have been signed to proceed.
Patient/Guardian's Signature*

Clear
Date

MonthDayYear
Date

Patient Name: {yourName} - DOB: {dateOf}
Transfer conditions from page 3 marked with a “P” for past health issue.

Please list: when, how long it lasted, description of symptoms (ex. Sharp, pain, burning), how often (ex. Weekly, daily), severity (0=no pain; 10=worst pain).
Past Health Issue*
PLEASE INDICATE IF NONE
Past Health Issue
Past Health Issue
Are any of these past conditions due to an accident?

YesNo
If Yes, what type?

WorkAutoPersonal
Date of accident

MonthDayYear
Date
Has your child seen any doctors for this condition:

YesNo
Please list the doctor specialty, & for how long your child was seen
List any past hospitalizations and/or surgeries:
Surgeries
My child has not had any surgeries
List Hospitalizations Other Than Surgeries:
My child has not been hospitalized
The above information is true and accurate to the best of my knowledge. Copies of any x-rays and reports will be released upon written request, however original x-rays remain the property of the clinic. I have been informed evaluation is not for neuromusculoskeletal conditions or evaluation of presenting complaints but for spinal and neurological functional capacity, spinal alignment and presence of spinal subluxation. Procedures recorded represent the limited evaluation procedures chosen to assess this particular patient. Appropriate informed consent documents have been signed to proceed.
Patient/Guardian's Signature:

Clear
Date

MonthDayYear
Date

What are your child life goals and where do you see your child in the next 10 to 20 years?
1st
2nd
3rd
4th
5th
6th
7th
8th
Patient/Guardian's Signature Printed Name
Date

MonthDayYear
Date
Patient/Guardian's Signature:*

Clear

So We Are On The Same Page….
A Statement of Clinical Objective

Hello. Welcome to Network Wellness Center.

The purpose in sharing this statement of clinical objective is to clearly define the approach to Chiropractic, healing that you will experience as a practice member at NWC and to detail our responsibilities to you in this exciting relationship.

The following concepts are central to the way in which Chiropractic is practiced at NWC. These ideas are shared with you so that your purpose and ours can be in alignment from the very beginning.

• There is an intelligence within you that keeps you alive and also animates, coordinates, repairs, renews, empowers, and heals.
• Your nerve system is a main coordinating system and distribution center for this Innate Intelligence.
• Alteration in the shape, position, tone, or tension of your nerve system, at the spinal level, will block, inhibit, or redirect the expression of this intelligence.
• Spinal Subluxations are an interference to the proper functioning of your nerve system and its ability to send, receive and coordinate life force and intelligence.
• Proper coordination, repair, movement, inspiration, empowerment, healing, can not be expressed when this life power and intelligence is blocked, or redirected.
• The purpose of the professional care at NWC is to assist in the reduction of spinal cord tension and associated vertebral subluxations and to develop and maintain spinal and nerve system integrity. This empowers a greater communication of this life power and coordinating intelligence. A healthier spine, nervous system and enhanced health and quality of life, is a desired outcome.
• Everyone, in spite of specific symptoms or ailments, can benefit from a more flexible, elastic, and subluxation-free spine and nerve system.
• Symptoms are not necessarily a sign of illness. They can occur to alert you to the need for change.
• Specific location of symptoms does not correlate to specific subluxations or areas of spinal tension needing to be adjusted. Severity of symptoms does not correlate to severity of subluxations. The reduction of symptoms is not an effective indicator of improved health.
• You may have symptoms and not need an adjustment on a particular visit. You may have no symptoms and may require extensive adjustments on a particular visit. Your symptoms are not necessarily in direct relationship your prognosis.
• Specific symptoms, conditions or ailments, other than vertebral subluxations are not treated. We do not imply that any particular adjustment or series of adjustments will have a direct effect on any symptom or condition you may be presenting. Research studies show improved physical and emotional health and well-being reported by thousands of patients receiving Network care.
• If you are having concerns about symptoms or ailments at any time during care, you should to consult with your physician.
• Your innate intelligence is the true agent of healing, empowerment, coordination, inspiration, movement, and joy. Healing is an inside job, coordinated by the same power that develops and renews your body.
• By their very intent, various treatments may interfere with the functioning of your nerve system. This may include drugs such as pain relievers, muscle relaxers, anti-inflammatory compounds, and mood altering medication. This can often prolong the time for spinal correction.
• Medication levels for a non-flexible body-mind stuck in sickness are not necessarily the same as for a body becoming well.
• You will not be advised by us about the need for reduction of medications. That is the job of a medical doctor, and you should speak with your physician to determine the objective and goal to be obtained by receiving a particular medical treatment. Determine if this is consistent with your desire for wellness at this point in time. Your physician may guide you in changing any medication or treatments you are presently utilizing to accommodate for your changing body-mind.

Sincerely,

Drs. Daniel & Richelle Knowles
Drs. Daniel & Richelle Knowles

INFORMED CONSENT

This office practices evidence-based spinal care. This practice is based on nationally recognized practice guidelines as well as published research conducted at numerous universities and chiropractic colleges. Our commitment to you is to deliver the safest, highest quality of life changing care that you can receive, focused on the reduction of spinal cord tension, spinal subluxations and the development and maintenance of spinal and neural integrity.

To begin care, your consent is needed to perform a history and physical evaluation focused on testing procedures and questions that solely relate to quality of life, stress levels, body awareness, spinal cord tension, spinal subluxations, and the loss of spinal and neural integrity. The intent of your evaluation is to assess your current level of spinal and neural integrity. From there a plan will be created to maximize your quality of life and degree of well being.

A differential diagnosis to detect the presence of or determine target treatment for any disease, condition, or symptom will not be performed. The only diagnosis you will receive is that of spinal subluxation. If you desire advice, diagnosis or treatment for any symptom, condition, disease or concern you should seek the services of a health care provider who specializes in that area.
I
Patient/Guardian's Signature printed name
have read and fully understand the above statements. I understand that the spinal adjustments offered in this office are not a replacement for any form of treatment provided by other types of practitioners. I understand that I am not being treated for any condition or symptom other than spinal tension, vertebral subluxation, and the associated loss of spinal and nerve system integrity. This office offers chiropractic as a form of health and wellness care, to promote the natural mechanisms for self healing and empowerment, as compared to specific target treatment. I therefore accept chiropractic care on this basis.
Patient/Guardian's Signature :*

Clear
Date

MonthDayYear
Date
Network Wellness Center

Network Wellness Center

2449 Pine Street

Boulder, CO 80302

303.998.1000

Notice of Privacy Practices -- Acknowledgement

We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. You may see your record or get more information about it by contacting Richelle Knowles, D.C.

Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed, and how you can access your information.

As required by the privacy regulations, I am aware that Network Family Wellness Center has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions effective for all protected health information that it maintains.

By my signature below I acknowledge receipt of the Notice of Privacy Practices, I provide Network Family Wellness Center, with my authorization and consent to use and disclose my protected health care information for the purpose of treatment, payment and health care operations as described in the Privacy Notice
Signature of patient or authorized reprensentative*

Clear
Date

MonthDayYear
Date
Printed name if signed on behalf of patient / Relationship (parent, legal guardian, personal representative, etc.)
This form will be retained in your health record.
Patient Id
Email
example@example.com
Should be Empty: