Greenville New Patient Paperwork

Patient Case History
Basic Information
Marital Status
Permission to Contact Physician
List any Allergies
List any Surgeries
List ALL Past Medical History / Conditions
List any Medications you are taking
List your Family History
Have you had any auto or other accidents?
Have you ever had chiropractic care?
Were X-Rays taken?
Do you smoke?
Do you drink alcohol?
Do you consume caffeine?
Do you exercise?
Please mark your areas of pain on the diagram below
How is your condition changing?
Have you had this condition in the past?
How often do you experience your symptoms?
Describe the nature of your symptoms
Please rate your pain on a scale of 1 to 10 (0 = no pain and 10 = excruciating pain)
How do your symptoms affect your ability to perform daily activities such as working or driving?
INFORMED CONSENT FOR CHIROPRACTIC CARE
Chiropractic Health
A patient, coming to the Chiropractic Physician, gives the doctor permission and authority to care for the patient in accordance with the chiropractic testing, analysis and diagnosis. The chiropractic adjustments or other clinical procedures are usually beneficial and seldom cause any problems. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible to injury. The doctor, of course, will not give any treatment or health care if he/she is aware that such care may be contraindicated. Again, it is the responsibility of the patient to make it known, or to learn through health care procedures whatever they are suffering from: latent pathological defects, illnesses or deformities which would otherwise not come to the attention of the Chiropractic Physician. The Chiropractic Physician provides a specialized, non-duplicating healthcare service. Your Doctor of Chiropractic is licensed in a special practice and is available to work with other types of providers in your health care regime.
I understand that if I am accepted as a patient by a physician at Chiropractic Health, then I am authorizing them to proceed with any treatment that may be necessary. Furthermore, any risk involved, regarding chiropractic treatment, will be explained to me upon my request.
I have read and will follow all directions as stated in the policy, to the best of my ability.
Patient Health Information Consent Form
Chiropractic Health
We want you to know how your Patient Health Information (PHI) is going to be used... Please read the HIPAA NOTICE...
Signature Section
CHIROPRATIC HEALTH
ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO CHIROPRACTIC HEALTH, PRIVATE/GROUP AUTO INSURANCE OR PRIVATE/GROUP HEALTH INSURANCE
I hereby instruct and direct the payment of all professional or medical expense benefits allowable and otherwise payable under my current insurance policy to Chiropractic Health as payment for professional services rendered: DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY
This payment will not exceed my indebtedness to the above mentioned assignee and I have agreed to pay in a current manner any balance of said professional service charges over and above the insurance payment. If my current policy prohibits direct payment to the clinic or clinic doctor, then I hereby instruct and direct payment to the owner of the business, Dr. Clint Dorn, and will submit to the appropriate clinic location where services were rendered: Chiropractic Health
Chiropractic Health Greenville
N1724 Municipal Drive
Greenville, WI 54942
Chiropractic Health Appleton
3020 E. College Ave, Suite H
Appleton, WI 54915
Chiropractic Health Neenah
835 Main Street
Neenah, WI 54956
Chiropractic Health Oshkosh
1765 Taft Avenue
Oshkosh, WI 54902
A photocopy of the Assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in said case.
Insured Signature
Chiropractic Health Representative Signature
CHIROPRATIC HEALTH
Text Message Alert Request Form
Personal Information
I give Chiropractic Health permission to send text message reminders about upcoming appointments or balance due reminders regarding my account.
Disclaimer: Message and data rates may apply. In other words, when you use our text message services, the only cost to you is whatever your wireless provider charges you to send and receive text messages. If you have an unlimited text messaging plan, there is no need to worry about additional rate charges.
Chiropractic Health Greenville
N1724 Municipal Drive
Greenville, WI 54942
Chiropractic Health Appleton
3020 E. College Ave, Suite H
Appleton, WI 54915
Chiropractic Health Neenah
835 Main Street
Neenah, WI 54956
Chiropractic Health Oshkosh
1765 Taft Avenue
Oshkosh, WI 54902

Thank you for taking the time to fill out this form.

Our Clinic Locations

Four Convenient Locations in Appleton, Greenville, Neenah & Oshkosh!