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Patient Introduction (please read carefully before completing)
We ask you to fill this out for either consultation or examination purposes. Examinations are done routinely to determine the nature and extent of your condition. The practitioner will explain the level of examination which is necessary for your type of condition. More detailed or specific examinations may be needed in complex or chronic cases to make confirmation.
Full Name Date
Phone Fax Email:
Complaints or existing condition: Current or previous primary care doctor’s name, specialty, phone number
What type of service do you desire? Temporary relief of symptoms / pain control Attention to removal of the tendencies causing our condition Balanced optimum health care: Elimination of root/cause of problem, if possible Maintenance care: regular balancing or “tune-ups” to keep in good health Seasonal Tune-ups: such as prior to allergy season or cold and flu season
How would you classify your condition? Minor Moderate Involved Fairly severe and progressively getting worse Serious
Consent for Service: I, the undersigned, am aware of both the benefits and risks of this service and give my consent for care. I fully understand that there is not implied or stated guarantee of success of effectiveness of a specific procedure to modality or services as such. I further realize our service, may not be covered at this time by Medicare.
As Patient/Client, I have read, understand and accept the above and consent for service. As Patient's Guardian, I have read, understand and accept the above and consent for service.
IT IS AGREED: The ATTENDING PRACTITIONER will provide health care and other services to the patient/client, to the best of his/her skill and knowledge, in the light of circumstance and what is possible and practical. The patient/client will cooperate fully with the practitioner by following his/her instructions and adhering to such treatment plan or course of action as may be set forth and agreed.
IT IS ALSO AGREED: I agree to hold harmless this practitioner or to present any issue or concern of medical malpractice by letter to the practitioner. If taken further, action will be decided by neutral arbitration, and therewith, I forego my right to jury or court trial should an issue arise. Because of the differences in human constitution and response, I understand that no practitioner can legally warrant the outcome of their medical care and service.
Patient, I agree with the above stated / Client, I agree with the above stated
Authorization to Release Information: I hereby authorize any physician, surgeon, practitioner, registered pharnacist or other person, any hospital, any medical service organization, any insurance company or any other institution or organization to release to you and you to them any medical or other information acquired concerning my condition or other disabilities. A photostat of this authorization shall be valid as the original.
I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment and fees for professional servicees rendered me will be immediately due and payable.
Person responsible for the account? Method of Payment: Cash Paypal The above statement by me are accurate to the best of my ability.
Patient, I agree with the above stated / Client, I agree with the above stated I as Guardian or Spouse's authorize care by checking this box.
Please submit only once to avoid duplicates
We welcome you to our office.
