Miracle Life Chiropractic

New Practice Member Application

Name *

Phone *

Email *

Date of birth *

Address

Street Address *

State *

City *

Postal Code *

Health Concern #1 *

Severity: 0 = no issues, 10 = unbearable *

How long have you had this problem? *

How many days a week do you experience it? *

Health Concern #2

Severity: 0 = no issues, 10 = unbearable

How long have you had this problem?

How many days a week do you experience it?

List all injuries/surgical operations & years: *

What have you done to try and get your problems corrected *

Chiropractic

Physiotherapy

Medication

common.other_option

List all over the counter & prescription medications you are on, & the reason for each: *

History of cancer: (and if so when) *

Known Thyroid condition? *

Where are your symptoms? *

See below image for reference

How would you describe your symptoms? *

For your MAIN problem area, what does it feel like? *

When your primary symptom is at its worst, what does it feel like? *

How would you rate your pain RIGHT NOW? *

What is your typical or AVERAGE pain? *

What is your pain level at its BEST? (How close to 0 does your pain get at its best?) *

What is your pain level at its WORST? (How close to 10 does your pain get at its worst?) *

Smoking: How often? *

Alcohol: How often? *

Exercise: How often? *

Have you consumed any products with caffeine in the past 48 hours? *

Yes

What are your symptoms affecting and/or what are you worried they will affect in the future? *

How has your health condition affected the boxes marked above? Please give examples for each: *

What would be better/different in your daily life without these symptoms? Please be specific: *

What are you most concerned with regarding your problem? *

Where do you picture yourself being in the next 1-3 years if this problem is not taken care of? *

What do you desire most to get from working with us? *

What would that mean to you? *

INFORMED CONSENT FOR CARE

Prior to receiving care in the 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 care is needed, or if any further examinations or studies are needed. In addition, this 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 care, and give consent to the examination and care that the doctor deems necessary, including spinal adjustments, as reported following my assessment.
Treatment objectives, as well as the risks associated with adjustments and all other procedures provided at Miracle Life Chiropractic have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.
I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related in one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments.
I authorize and request payment of insurance benefits directly to Miracle Life Chiropractic. 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 practice member. 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 all charges not covered. In the event of any legal action or proceeding relating to the subject matter of this agreement, the non-prevailing party shall reimburse the prevailing party for all reasonable attorney fees and costs resulting therefrom.
For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by, or anyone authorized by Miracle Life Chiropractic, of any and all photographs/videos which you have taken of me, for the purpose of promotional TV and/social media/or print ad, whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Miracle Life Chiropractic, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. I hereby irrevocably consent to and authorize the use of audio recording. The purpose of recording is for use in training and supervision. This will allow Miracle Life Chiropractic team members to consult with his or her assigned supervisor(s) in an individual or group supervision format, who may view the recording alone or in the presence of other team members-in-training involved in direct supervision or training course. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws).

Print Name: *

Date: *

Signature: *

Clear

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT

I understand that I have certain rights of privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: 1. Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. 2. Obtain payment from third-party payers. 3. Conduct normal healthcare operations, such as quality assessments and physicians certifications. I acknowledge that I may request your NOTICE OF PRIVACY PRACTICES containing a more complete description of the uses and disclosures of my health information. I also understand that I may request, in writing, that you restrict how my private information is disclosed to carry out treatment, payment, or healthcare operation. Release of Information:

I authorize the release of information including the diagnosis, records; examination rendered to me and claims information. *

Yes

This information may be released to: *

Spouse

Child(ren)

Other

Information is not to be released to anyone else

This Release of Information will remain in effect until terminated by me in writing.

Signature:

Clear

Date:

X-RAY AUTHORIZATION

As your healthcare provider, we are legally responsible for your medical records. We must maintain a record of your x-rays in our files. At your request, we will provide you with a copy of your x-rays. Digital x-rays on a CD will be available within 72 hours of any regular practice hour day. Please note: X-rays are utilized in this office to help locate and analyze vertebral subluxations. If any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice.

By signing below you are agreeing to the above terms and conditions.

Full Name

Signature:

Clear

Date:

FEMALE PRACTICE MEMBERS ONLY: To the best of my knowledge, I BELIEVE I AM NOT PREGNANT at the time the x-rays are taken

Clear

Date:

CONFIDENTIAL MEDICAL INTAKE

Begin Your Intake

Miracle Life Chiropractic

New Practice Member Application

INFORMED CONSENT FOR CARE

NOTICE OF PRIVACY PRACTICE ACKNOWLEDGMENT

X-RAY AUTHORIZATION