Patient Forms

Name(Required)

First Middle Initial Last

Address

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Date of Birth(Required)

Sex(Required)

Male

Female

Non-binary

Emergency Contact

Name

First Last

Relationship to Patient

Emergency Contact Phone

Please list all current medications being taken:

Are you pregnant?

Yes

No

If yes, how many weeks pregnant are you?

Have you lost time from work as a result of the accident?

Yes

No

Last day worked:

Type of employment:

Are you being compensate for time lost from work?

Yes

No

If yes, please state type of compensation you are receiving:

Do you notice any activity restrictions as a result of this injury?

Yes

No

If yes, please describe in detail:

Other pertinent information:

PATIENT’S AFFIRMATION OF RECEIPT OF PATIENT’S STATEMENT OF PRIVACY RIGHTS

I hereby acknowledge receipt of this office’s Statement of Privacy Rights, provided on my behalf and in accordance with law and have read and understand my rights to privacy and security of Personal Health Information, as a patient of this practice.

ASSIGNMENT OF BENEFITS AND POWER OF ATTORNEY TO CASH CHECKS

I, the undersigned, do hereby authorize payment directly to the office below, the benefits of my coverage, if any, otherwise payable to me for services but not to exceed the customary charge for those services. If these payments are made out to me I grant unto the office below as attorney the full power and authority in my name and stead to endorse any and all checks and drafts or money orders. I hereby authorize the doctor to release all information necessary to secure payment of benefits. A photocopy of this assignment shall be valid.

INFORMED CONSENT FOR CHIROPRACTIC CARE

A patient, in coming to the Chiropractic Physician, gives the doctor permission and authority to care for the patient in accordance with the chiropractic tests, diagnosis, and analysis. 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 is aware that such care may be contra-indicated. Again, it is the responsibility or the patient to make it known, or to learn through health care procedures whatever he is 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 health care service. You 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 Gulf Coast Sport and Spine, LLC, 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.

Signature

Date

Patient Forms

New Patient Intake Form

New Patient Form

Emergency Contact

Surgeries

Social History

Occupational Activities

Review of Symptoms

Cardiovascular

Respiratory

Allergic/Immunologic

Gastrointestinal/Genitourinary

Neurologic

Consitutional

Psychatric

Endocrine

Hematologic

Ear, Nose, and Throat

Musculoskeletal

Additional Medical Conditions

Symptoms

Auto Accident

PATIENT’S AFFIRMATION OF RECEIPT OF PATIENT’S STATEMENT OF PRIVACY RIGHTS

ASSIGNMENT OF BENEFITS AND POWER OF ATTORNEY TO CASH CHECKS

INFORMED CONSENT FOR CHIROPRACTIC CARE

Alternate Form