New Patient Paperwork (Pediatric)

Welcome to Hands-On Healthcare & Chiropractic!

Please fill out the following questions as completely and accurate as possible to give our staff as much information as possible about you and your condition. You may text or call us with any questions you may have. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.

Patient Information

Childs First Name*

Childs Last Name*

Birthday*

Current Height*

Current Weight*

Gender*

Please select one option

Female

Male

Parent/Guardian Name*

Parent/Guardian's DOB

Phone # (N/A if not known/needed)*

Parent/Guardian Name*

Parent/Guardian's DOB

Phone # (N/A if not known/needed)*

Email*

Street Address*

City*

State/Province*

Please select one option

Zip Code*

How did you hear about us?*

Health Insurance

You may ignore this section if you send a picture of the card or plan to give us the card to scan in when you come into the office.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself .I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

Insurance Company

Policy #

Group #

Address

Phone Number

Health Questionnaire

Please mark an X where you feel pain, numbness, tingling, etc.*

Please fill in area

How long have you been dealing with this injury?*

Please select at least one option

an acute (0-3 months)

a sub-acute (3-6 months)

a chronic (over 6 months)

a recurring

How did this injury or condition occur?*

Please select one option

If you answered other above, please explain.

When did the condition begin? (MM/DD/YYYY)*

How often do you feel this discomfort?*

Please select one option

If you answered other above, please explain.

What is quality of discomfort?*

Please select at least one option

If you answered other above, please explain.

If the discomfort radiates, Is your pain travelling elsewhere? If not, choose non-radiating*

Please select at least one option

Is complaint getting better, worse or staying the same?*

Please select one option

improved (decreased)

stayed the same

worsened (increased)

What would you rate your pain on a scale of 1-10 (10 being worst)*

Please select one option

What is the symptom relieved by?*

Please select at least one option

If you answered other above, please explain.

Any past episodes of this complaint?*

Please select one option

OTHER

confirms

denies

Have you received any past care for this complaint?*

Please select at least one option

If you answered other above, please explain.

What activity of daily living most affected?*

Please select at least one option

If you answered other above, please explain.

Do you have any pain in your lower back when sneezing, coughing, or using the bathroom?*

Please select one option

Yes

No

Have you lost any control of your bladder or bowel movements?*

Please select one option

Yes

No

Does you pain increase at night time?*

Please select one option

Yes

No

Is your pain unrelieved by position or rest?*

Please select one option

Yes

No

Any traumas (car accidents, falls, trips, spills, etc) in your life?

Yes

No

If yes, please list what kind and when.

Have you ever had surgery?

Yes

No

If yes, What surgeries were done?

Have you ever had MRIs done?

Yes

No

If so, where were the images taken and of what area?

Have you had X-rays done within the last year?

Yes

No

If so, where were the images taken and of what area?

Health Habits & Conditions

Do you have a Primary Care Provider?

Yes

No

May we contact your Primary Care Provider if need be?

Yes

No

If yes, what is the Primary Care Provider's name?

Do you smoke or vape?

Yes

No

Do you drink alcohol?

Yes

No

Do you drink caffeine?

Yes

No

Do you exercise regularly?

Daily

Moderately

Occasionally

No

Do you wear:

Heel lifts

Sole Lifts

Inner Soles

Arch Supports

Please list any medications and/or vitamin supplements you are currently taking?

Has your child ever suffered from: check applicable items

Do you have any other health concerns you wish to be reviewed during your examination? If Yes, please list below.

Family History - Has anyone in your family experienced any of the following?:

Experience with Chiropractic

Have you been adjusted by a chiropractor before?

Yes

No

Doctor's Name

Approximate date of last visit?

Any known complications with chiropractic care?

Hands-On Health Care & Chiropractic Therapy specific questions

Chiropractic examination and therapeutic procedures (including spinal adjustment, heat application, ice application, electrotherapy, manual muscle therapy, spinal decompression, flexion, Class IV Laser, Shockwave, Whole Body Vibration, and Winback therapies) are considered safe and effective methods of care. Occasionally, however, complications may arise. While the chances of experiencing complications are small, it is the practice of this office to inform our patients about them. These complications included, but are not limited to: redness, soreness, inflammation, soft tissue injury, dizziness, bruising, and temporary worsening of symptoms. More serious complications are extremely rare. Additional information on side effects and complications is available upon request. I do not expect the doctor to be able to anticipate and explain all risks and complications. I have read the above statements regarding treatment side effects and understand that there is no guarantee or warranty for a specific cure or results. Furthermore, it is my responsibility to inform the doctor or clinical staff if there are in changes to my health.

Please answer the following questions.

Do you have a pacemaker or any other implanted devices?*

Please select one option

Yes

No

Do you or have you had cancer or previous area specific infections?*

Please select one option

Yes

No

Have you had a steroid injection in the last 7 days?*

Please select one option

Yes

No

Are you taking any medications that may increase your sensitivity to light or burn easily from sunlight?*

Please select one option

Yes

No

Do you have any allergies to ultrasound gel, isopropyl alcohol, or latex?*

Please select one option

Yes

No

HIPAA COMPLIANCE PATIENT CONSENT

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or health operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practices does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent.

Please answer the following questions.

May we leave a message on your answer machine at home or on your cell phone?*

Please select one option

Yes

No

May we phone, email, or send a text to you to confirm appointments?*

Please select one option

Yes

No

May we discuss your medical condition with your family? If yes, please state their name and relation to you below.*

Please select one option

Yes

No

Name?

Relation?

Name?

Relation?

Insurance:

We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate care plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. I understand that if I fail to provide accurate insurance coverage information to Hands-on Health Care and Chiropractic will not be able to file my claim within the prescribed time limits and I, therefore, forfeit any and all rights to insurance benefits that would have been available to me. This includes any benefits that would have provided discounts, deductible and other amounts that would have otherwise not been my responsibility as a patient. I further understand that Hands-on Health Care and Chiropractic will not be responsible for filing claims on my behalf {or on behalf of any dependents) if I produce my insurance coverage information more than three days after services are rendered. In addition, I understand that preventative care is not covered under insurance plans and this is my responsibility to pay for the service when rendered. I acknowledge my awareness of this policy and agree to produce my insurance coverage information.

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Agreement:

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives.
The risks associated with exposure to ionization, and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request, and authorize imaging studies, and chiropractic adjustments, for the benefit of my minor child, for whom I have the legal right to select, and authorize health care services on behalf of. Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse /former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office. My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.
My signature below signifies that I have read and agree to the above statements.

Signature*

Date Signed*

Printed Name*

Email*

Parent/Guardian's Signature*

Re-exam Paperwork

Tarpon Springs

New Port Richey

New Patient Paperwork (Pediatric)

Welcome to Hands-On Healthcare & Chiropractic!

Patient Information

Health Insurance

Health Questionnaire

Health Habits & Conditions

Experience with Chiropractic

Hands-On Health Care & Chiropractic Therapy specific questions

HIPAA COMPLIANCE PATIENT CONSENT

Insurance:

Authorization for Care:

Agreement:

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