New Patient Forms

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

Patient Introduction

Patient Information
Emergency Contact Information
Financial Information

Primary Insurance
Secondary Insurance

It is Usual and Customary to Pay for Services as Rendered Unless Otherwise Arranged

Patient Case History

History of Current Condition
For this CURRENT condition. have you:
Health History

Family Health History

Past Health History(Please list any past...)

Social and Occupational History

Are you currently experiencing any of these symptoms? (Cheek all the apply)

Many of the following conditions respond to Chiropractic and Acupuncture treatment.

Review Of Systems

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office to provide me with chiropractic care, diagnostic testing, and/or therapeutic services, in accordance with this state's statutes.

Island Chiropractic

14602 Compass, Suite B, Corpus Christi, TX 78418
Ph: 361.949.2199 Fax: 361.949.2847

Island Chiropractic

Halth Insurance Portability & Accountability Act (H1PAA) Consent Form

Your Protected Health Information (PHI) will be used by this office or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office. You should review the Notice of Privacy Practices for a more complete description of how your PHI may he used or disclosed. It describes your rights as they conesrn the limited used of health information. including your demographic information. collected from you and created or received by this office. You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk. This office reserves to right to modify the Privacy Practices outlines in the Notice.

Requesting a Restriction on the User or Your Information

You may request a restriction on the use or disclosure of your PHI. it is the policy or this office that it will continue to provide treatment for a patient who restricts consent to the use and disclosure of his/her PHI for the purposes of treatment, payment, or health care operations. Use or disclosure of protected information in violation of an agreed upon restriction will be violation of the federal privacy standards.

Revocation of Consent

You may revoke this consent to the use and disclosure of your PHI. You most revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Assignment of Benefits / Assignment of Cause of Action / Contractual Lien

Our office will make every attempt to verify your policy benefits. however, this office and your insurance DOES NOT guarantee a quote of benefits for payment of services provided. Should your insurance provide Chiropractic benefits, your insurance will be filed on a weekly basis as a courtesy to you. You will be responsible for your deductible and/or co-payment. Your insurance should pay within 45 days from the date in which it was filed. In the event that your insurance company does not pay a timely manner, you may be asked to contact your insurance carrier. If your Insurance company mails a check directly to you for our services, you must bring the misdirected check to our office within 48 hours.

Assignment of Rights and Conveyance of Lien Interest

I hereby execute and provide Irrevocable Lien Interest and Assignment of Proceeds to any cause of action that exists in my favor against any insurance company for the terms of the policy, including the exclusive, irrevocable right to receive payment for such services. make demand for payment, and prosecute and receive penalties, interest, court Ioos, or other legally compensable amounts owed by an insurance company in accordance with Article 21.55 of the Texas Insurance Code to cooperate, provide information as needed to assist in the prosecution of such claims for benefits upon request.

To any insurerce company providing benefits or settlement of a claim, you are instructed that pursuant to this Irrevocable Lien Interest and Assignment of Proceeds to pay the total dollar amount of all sums which I owe on account to the above named doctor and treating facility within 30 days following your receipt of medical bills submitted by the doctor and/or treating facility.

I instruct checks to be made payable to Island Chiropractic, payment to be sent to 14602 Compass, Suite B, Corpus Christi, Texas 78418. This demand specifically conforms to Article 21.55 of the Texas Insurance Code, providing fur attorney fees, 18% penalty, court cost, and intaest from judgment, upon violation. In the event my insurance settlement proceeds are paid directly to my attorney, I hereby irrevocably insuuct my attorney to withhold all such sums and amounts as are determined to be owed, due and payable on my account and remit payment of all such sums directly to the above named doctor and/or treating facility upon receipt of my settlement award(s).

Informed Consent for Treatment

I hereby authorize release the doctor and any individual he/she may designate at his/her assistant to adminimer treatment, physical examination, x-ray studies. chiropractic care or any clinical services that he/she deems necessary in my case. I understand that, as with any health care procedures. complications are possible following chiropractic manipulation and/or manual therapy techniques. The risks of complications due to chiropractic treatments have been labeled as "rare" and the probability of adverse reaction due to ancillary procedures is also considered "rare".

I, the undersigned parent or legal guardian of (minor child), hereby give my permission to the staff of Island Chiropractic to treat said child.

I hereby acknowledge that if I do not keep appointments as recommended to me by my treating deem, he/she has complete right to terminate responsibility for my care and relinquish any disability granted me within a reasonable period of time. I understand that failure to complete my recommended treatment plan may jeopardize by case.

This portion is only needed if the consultation will be in reference to an Accident or Injury.

Accident / Injury Questionnaire

Automobile Accident - Aditional Information

Worker's Compensation Injury - Additional Information
General Accident / Injury Information - (please use the reverse side of this page if additional space needed)
Before the accident/injury:
At the time of the accident/injury:
Since the accident/injury:

Finalizing Form

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