(srare) (zip) - Grand Island Chiropractic

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PATIENT HISTO,RY (Please Print)
(Please feel froe to add information to thE
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of this rsheet)
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l.
Name:
Date of
Address:
(Steet)
Mari+4sfffus:_
Birth' _ii-:
_.- _ _Sex: M F
(ciry)
(srare)
Weight:
lelgnt:
(zip)
Cell Phone:
r appolnunollt rern glders)
iiGroup #:
Phone:
FoWdirt you hear' ebout"bs? Glease explai
Are yW'purrenfly working? Yes or No *tf
Would your enrifioyer be intergted in cornpli
Oeoupatioru&' Ntme o f Employer :
A$feuu of Emp,loyer:
loyment:
by our doctors?
***+ffigg You HtrRT AT Wodfi?
YES or NO
+***Y6ffi YOU HTJRT IN AN AUI'OMO ILE ACCIDENT?
]
YES or NO
i
i,
Dst6ffSg?f,'s$bnting comp{aint(s) in detail
t'
:
PafB
your syrnptoms BEG
Give'cotdplote description of HOW your
iFte
Chiropqactor previo
'I&ve
X-fays, IrfRI, CT-Sca,n, Bone
Wbere:
Hatf you
been treated
ftr
or suspec
preseot!
YES or
, or
Blood Wo
(Please Circle?)
When:
of having cabcer fln the past or
Li$ ALL med'ications, vitamins, minerals,
al
lergies/reactions you
ti6ve:
i'b.or had AIIIY:ascideuts or
If
yes:
flave.you had AltlY surgeries or fraotures:
fst along with the approximate date:
FtsAse
Wbo to contad
Signotr,ue:
uries; YES,qr NO,
se doscrlbe lh deti
SorNQ
I
in case of an Erneigenc),:
I
Dttte:
.,
I
r Phone:
GRAND ISLAND CHIROPRACTIC
2283 GRAND ISLAND BLVD
GRAND ISLAND, NY T4072
(Town Hall Plaza)
(716\773-2222
FAX (866) 907-61s7
NOTARO CHIROPRACTIC
I0T58
58 MAGARA FATLS BLVD
BL
Parient Name:
AUTHORIZATION FOR RELEASE OF RECORDS:
.,
l.o
, = . _.
_., Iherebyauthorizeyouto
diagnosis and records of any treatment or exanr.inatioh ren<jered
,.
Dale:
r
:
Signaturer;
AUTHOzuZATION FOR
1l
I
Wirnless._
OF BENEFITSI
I aurhorize paymont of any medical benefitsto be pald dirootly to
-
rlease to CRFND ISL4ND CHIROpRACftC any inioqlrarion inc ludj
me drrrirrg rgy period ql'itrearmenr.
IslandiQhiropracfip Office for any service rendered ro rne,
Signature:
NOTICE OF PATIENT PRIVACY
By signing the below, I cenifu that I have received antJ r.eviewcd
language that I can understand, I also understand rhar rlris olfice
authorized penonal have access to this information,
Name(Printed)_
h
is nolice and all ol'nryIuesrions have been answered ro m.v sarisf'acrio,
s electronic records rh{t are secure and passwold prolecled and lhat on
Signature:
Wirness:
I
;
S
i
ignature of Legal Representative
tex.Anorney-ln-Facq Guardian, Parenl if a
Re
nr
larion sh ip
inor)
CONSENT TO TREAT
I have received information about my condition and proposed chi
bcnefits, the risks and the side sffects ofthe neatrnent and consec
rhar, as in allheal0r care, in the practice of chiropractic there are
sprains. fractures, dislocations, disc injuries and strokes, I do not e
I wish to rely on the doctor to exercise judgmenr during rhe course
krrown, is in my best interest. My doctor has responded ro all ot'nr
Irave had read to me, the above consenr. I have also had the opp
i
ic rrearment progrpfn as well as alternarive courses olcare, rhe
rces ofnot hgving the froposed |rodtsnenr, I understand and am inforr
re risks to trEatmcnt, irppluding but not limited to, muscle strains and
pect the doc{or to be afp to anticipate or explain all risks and complica
f the trearmqnts whichiihey feelar the rime, based upon rhe facrs rhen
requests lor:'infornrari$n abour the proposed rrealtnenl. I havc read. or
tiry lo ask question abpur ils contenr. tsy signing below, I consenr ro
treatment.
Signature;
;i
.li
I understandthat lmay be financially responsible for any charges i cuned at rhis,
office, ind.|uOing co,paymenrs, deducribles, all collecrion
ilrrclior legal fees on any unpaid account |el'erred for collecrion, and :harges
denied ol norcfvered by my insurance cpmpany. I realize my
nray be subject to pre,authorization by lhe irrsulance contpany, and
acceptan),responsibil[,ry [br charges, which may not be approved. Tt
ilrsulance compsny will revie w any/all docunrentation submilled
Cland lsland Chiroplad.tic for review l'or meclical necessity and base rf
approval/de.nial upon this documentation, lnsurance pol icy limirari
ns are per individual inlburance policy plans, as are co-payments. co.
insurance, deductibles, referrals etc. I ruderstand thai this office ar
to notiry me if a se{Vice is not covered and will nori} me if rhe
insurance company does not approve my care as soon as possible, I a
freatmen't plan is approved, this office will make me aware of rhe
of office visits allowed, lnitial visits may be denied and rhi may be beyqnd the office's abiliry
to notiry the parienr priorro render
'umber
acure
care, while waiting for the insurance coverage approval. The
charges willl be the
t's responsibility if denied by the insurance
company. This office may seek payment from you forany services
ur health lnburance plpn determine to be not medically necessary.
I have read and understand my obligations fcrr paymenr lbr care in
absence ollinsurance lpo verage.
GRAND ISLAI\D CHIROPRACTIC
2283 GRAND ISLAND BLVD
GRAND ISLAND, NY 14072
(Town Hall Plaza)
NOTARO CHTROPRACTTC
101F8 Niagara Falls Blvd
Niagara Falls, NY 14304
(C{mo Airport Plaza)
(716) 773-2222
FAX (866) 907-6rs7
rA)[
THOMAS J.
ANDREW C.
MICFIAEL C.
KATHY
CONSENT TO
(Parent/Guardian
ARO, D.C.
REEN, D.C.
AASE, D.C.
D, L.M.T.
T A MINOR
herebfi authorize to have
- Print Name)
my son/daughter
treatment from Thomas J. Notaro, D.C. Andrew C. Green,
Baase, Kathy Good, L.M.T.
Signature
(716) 2980368
(866) e07-6rs7
receive
.C., Micheal C.