NEW PATIENT REGISTRATION FORM

  • ROBICHAUD CHIROPRACTIC

  • 56 Winthrop Street
    West Concord, MA, 01742
    Phone: 978-369-2266
    Fax: 978-369-5205
    www.drrobichaud.com

  • PATIENT INSTRUCTIONS

  • We ask patients to arrive 15 minutes before your appointment time to prepare for your visit. Please print the new patient forms and fill them out before your visit. This will cut down on wait time and preparation time. These forms can be found on our website.

  • PARKING

  • There is plenty of free parking in the front of the building. If you need directions please feel free to call us at 978-369-2266.

  • HOURS OF OPERATION

  • Monday: 9:30am-4:00pm
    Tuesday: 9:00am-12:00pm 4:30pm-8:00pm
    Wednesday: 9:30am-4:00pm
    Thursday: 9:00am-12:00pm 4:30pm-8:00pm
    Friday: 7:30pm-12:00pm
    Saturday: 9:00am-12:00pm

  • URGENT CARE

  • Monday: 4:00pm-5:00pm
    Tuesday: 12:00pm-1:00pm
    Wednesday: 4:00pm-5:00pm
    Thursday: 12:00pm-1:00pm
    Friday: 12:00pm-1:00pm
    Saturday: 12:00pm-1:00pm

  • URGENT CARE SLOTS

  • We have urgent care hours every day which we don't schedule until the same day. You can either call the office and leave a message before 8 AM, on the urgent care line, or email us before 8 AM and leave us an email message. We generally check the emails before the voicemails. If you want to wait until the staff is in, and speak with them directly you can call the office between 8:30 AM and 9:00 AM. There is a $15 surcharge for services rendered during the urgent care hour; this surcharge must be paid before any urgent services are rendered.

  • MRI'S OR X-RAYS

  • If you have any recent MRIs done in the year prior to your visit please bring them to your appointment. CD copies are preferred over films of the MRIs or X-rays.

  • INSURANCE REFERRALS

  • If your insurance requires a referral to see a specialist, your are responsible for obtaining it from your primary care physician prior to your appointment and making sure we receive it. If we have not received the referral, you will be asked to sign a waiver stating that you are aware that you are being seen without a referral and no further appointments or diagnostic tests will be scheduled. Please fax all referrals to Robichaud Chiropractic at 978 369 5205

  • CO-PAYMENTS

  • If your insurance requires a co-payment it is due at the time of your appointment. We accept payment in the form of credit cards, personal checks, and cash. It is not unusual for bills to change once they have been processed through insurance. If you have any questions about insurance coverage or billing please call us at 978-369-2266.

  • PATIENT HISTORY & ASSESSMENT

  • PATIENT INFORMATION

  • DOB:
     - -

  • PRIMARY CARE PHYSICIAN

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • REFERRING PHYSICIAN

  • Format: (000) 000-0000.

  • HISTORY OF YOUR PAIN/SYMPTOMS

  • CIRCLE THE BEST ANSWER

  • 1. What event(s) led to your original Symptoms?
  • 2. Since the time of onset, my symptoms have:

  • ACTIVITY

  • Rows

  • DESCRIPTION OF CURRENT PAIN

  • Date of current onset
     - -
  • Pain Frequency
  • Pain is worse
  • Your Paint Tolerance
  • Description of Pain (check all that apply)
  • What relieves pain (check all that apply)
  • On a scale of 0 to 10 with 0 being no pain and 10 being the highest, rate your pain now
  • When I have pain it makes me feel (check all that apply)
  • PAST MEDICAL HISTORY (Check all that apply)

  • SOCIAL HISTORY

  • Working Status (Check all that apply)
  • How would you classify the level of movement at your occupation (Check all that apply)

  • BEHAVIORAL HEALTH

  • Do you smoke?
  • Do you drink more than two alcoholic beverages per day?
  • Do you use street drugs/narcotics?

  • FALL RISK ASSESSMENT

  • Have you fallen in the last 6 months (not a slip or a trip)?
  • Are you feeling weak, dizzy, or lightheaded today?
  • Do you need help to walk or change your clothes?

  • FUNCTIONAL STATUS

  • Do you use any of the following?
  • Do you exercise?

  • CONCORD HEALTH CENTER

  • INFORMED CONSENT FORM FOR CHIROPRACTIC TREATMENT

  • I hereby request and consent to the performance of chiropractic adjustments and any other chiropractic procedures to be performed on myself, or the patient named below, for whom I am legally responsible. This includes, but is not limited to examination tests, diagnostic x- rays and physiotherapy techniques which are recommended by Dr. Jeffrey Robichaud who will be rendering treatment to me.
  • I understand that, as with any health care procedure, there are certain complications which may arise during a chiropractic adjustment. These include, but are not limited to, fractures, dislocations, muscle strains, Horner's Syndrome, diaphragmatic paralysis, cervical myelopathy, costovertebral strains and joint separations. Some forms of cervical manipulation have been associated with injuries to the arteries of the neck leading to or contributing to serious complications- including stroke. This is a very rare occurrence, estimated at 1:3,000,000. We screen our patients for contraindications to cervical manipulation to the best of our ability.
  • I DO NOT expect Dr. Robichaud to be able to anticipate all of the risks and complications. I do expect the Doctor to exercise good judgment during the course of care performing procedures which are in my best interest in both safety and efficacy.
  • I have read, or have had read to me, the above explanation of chiropractic adjustments and related therapies. By signing below, I am stating I have weighed the risks involved in undergoing treatment, and have decided in favor of moving forward with care. Having been informed of the risks, I hereby give my consent to that treatment. I intend this consent to cover the entire course of care for my present condition and for future conditions for which I seek treatment.

  • CONSENT TO USE AND DISCLOSE HEALTH INFORMATION

  • 1. Permission to use and disclose my private health information: By signing this form I give Dr. Jeffrey Robichaud permission to use/disclose my private health information for the purposes of carrying out treatment, obtaining payment for services rendered or for routine office operations related to my care.
  • 2. Right to Refuse: I have the right not to sign this consent. If I refuse to sign this consent, Dr. Jeffrey Robichaud will not be able to provide me with any treatment until such time that I agree to sign. However, in the event of an emergency where Dr. Jeffrey Robichaud is required by law to render emergency care my consent is not required.
  • 3. Right to review notice of privacy practices: Dr. Jeffrey Robichaud has provided me the opportunity to review the privacy practices of the office regarding the disclosure of protected health information.
  • 4. Changes to the privacy notice: Dr. Jeffrey Robichaud may change the notice of privacy practices as needed. I may obtain a copy of the revised practices by contacting the office directly.
  • 5. Right to request restrictions on use/disclosure of information: I have the right to request that Dr. Jeffrey Robichaud restrict the use of protected health information for the purposes of treatment, payment or operations. However, I understand Dr. Jeffrey Robichaud is not required to agree to these requested restrictions. This request must be made in writing and Dr. Jeffrey Robichaud will give a written reply to my request within 48 hours of it's receipt.
  • 6. Right to withdraw consent: I have the right to withdraw this consent at any time. I must do so in writing. My withdrawal of consent does not impact information disclosed or used prior to the request for withdrawal. If I withdraw my consent I understand Dr. Jeffrey Robichaud will no longer be able to provide me with treatment, unless required by law for emergency purposes.
  • 7. Effective period: This consent is good from this date forward, unless I withdraw my consent in writing.
  • 8. References to "I" and "me": References to "I" and "me" in this document include the individual for whom the signing party is authorized to sign. If I am signing this consent on behalf of another person, such as a minor child, it is because I am the legal guardian, parent of agent under an active power of attorney. I acknowledge I am legally authorized to sign this consent on behalf of the individual.
  • Date:
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  • Should be Empty: