PATIENT INFORMATION. We will not share your information. Occupation/Job: Employer: Work Address: City, State, Zip EMERGENCY CONTACT INFORMATION

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1 PATIENT INFORMATION Date of Birth: Sex: M F Age: Soc. Sec. #: - - Photo ID #: State: Address: City, State, Zip: Mobile Phone: Home Phone: Work Phone: address: I want to be notified of appointments or health information via text phone May we you newsletters or coupons? Yes No Married yes no Children: # Drivers License: State # We will not share your information. Occupation/Job: Employer: Work Address: City, State, Zip How did you find this clinic? Google Yelp Insurance Referral: Other: The Affordable Care Act (ObamaCare) requires that we ask the following information. You may refuse to answer these questions. Ethnicity: Hispanic Non-Hispanic Preferred Language (if other than English): Race: Native Alaskan/Native American Asian Black Pacific Islander White Smoking Status: never smoked former smoker daily smoker smoke occasionally heavy smoker Drug Allergies: none We will not share your personal information with anyone, except your insurance company and as required by the Affordable Care Act, without your permission. Please refer to our HIPAA documentation for details of our privacy policy. EMERGENCY CONTACT INFORMATION Whom may we contact in case of an emergency? Name: Relationship: Phone #: Address: City, State, Zip: Primary Physician: Phone #: Address: City, State, Zip: Signature: Date:

2 AUTOMOBILE ACCIDENT INFORMATION Date of Accident: Time of Accident: # of people in your vehicle Injured? Yes No Did the police come to the accident? Yes No. Was a police report filed? Yes No Traffic violation given? No Yes To whom? Location of accident: Where were you seated? Driver Front Passenger Rear (left, right, center) Child Seat What type of vehicle were you in? What other vehicles were involved? How did the accident happen? What was your speed? Other vehicle s speed? Were you wearing a seatbelt? No Yes Did airbags (SRS) deploy? No Yes Was your headrest high? middle? low? Were you braced for impact? surprised? Your left right both hands were on the steering wheel dash seat lap window sill Your left right both feet were on the brake pedal gas pedal floor Did any part of your body strike anything in the vehicle? No Unsure Yes, Did you lose consciousness (black out)? No Unsure Yes, for What symptoms did you notice immediately following the accident? minutes/hours Were you treated at the accident site by nobody paramedics someone else? Whom? Did you go to the hospital? No Same day by ambulance by car another day? Which hospital? What treatment was provided? Were x-rays or MRI taken? No Yes What did the tests show? When did you start to feel your current symptoms? Same day Next day Other: Have your symptoms stayed the same gotten worse gotten better? List any other treatment or medications you have had for this accident: Have you ever experienced similar problems? No. Yes,

3 Please mark the location of damage to your vehicle on this diagram, using the key below. ///// = mild \\\\\ = moderate XX = severe Do you currently have any other symptoms or conditions not related to this accident? Are you currently receiving any other treatment, including medications, for separate problems? None Yes List any allergies. None List any surgeries. None List any other hospitalizations. None List any major accidents or illnesses. None List any personal history of major illnesses (cancer, diabetes, stroke, heart disease, etc.) None. List any family history of major illnesses (cancer, diabetes, stroke, heart disease, etc.) None. Do you have any metal objects in your body (shrapnel, IUD, pins, staples, etc.)? No Yes List any recreational drugs (alcohol, coffee, tea, tobacco, marijuana, narcotics, etc.) that you use Any other complications? None ***Females only: Are you pregnant? No Yes. Due Date? If your pregnancy status changes during the course of your treatment, please inform the doctor. Other comments: If you notice any change in your symptoms, be sure to notify Dr. Bryson. Signature of Patient or Guardian Date

4 Pain Diagram Height: in. Weight: lbs. Please describe all your symptoms or pain on the pictures below, using the following symbols: A=Ache B=Burning T=Tingling N=Numbness S=Stabbing =Shooting O=Other Rate your pain on a scale of 0 to 10, where 0 = no pain and 10 = the worst pain imaginable. Either place a mark on the scale below, or write the pain level next to each symptom on the picture. For example, on the shoulder you could write A4 to indicate aching pain at level 4/ No Pain Much Pain Since starting treatment for this I feel better same worse This is a new episode. What is the main problem today? When did this most recent episode start? The symptom is present 0% % of the time. It prevents daily activities 0% % of the time. How did it start? What makes it worse? What makes it better? Are you able to work? Yes No With difficulty What treatment have you tried? Did it help? Have you had this problem before? No Yes Was it resolved? No Yes When? Signature of Patient or Guardian Date

5 Pkwy Suite 309 Building 4 MOTOR VEHICLE INSURANCE INFORMATION Date of Accident: Were you the driver passenger pedestrian other Others involved in accident: Your Insurance Co: Phone #: Address: City, State, Zip: Claim #: Policy/Group # Insurance Adjustor: Phone #: Fax #: Do you have Personal Injury Protection (PIP) on your policy? Yes no Responsible for the accident: Me Other (name) Insurance Co: Phone #: Address: City, State, Zip: Claim #: Policy/Group # Insurance Adjustor: Phone #: Fax #: Do you have legal representation? Yes No Attorney Name: Phone #: Fax #: Patient or Guardian Signature: Date:

6 Name of Patient: MISSED APPOINTMENT, ASSIGNMENT OF BENEFITS, INFORMED CONSENT, AND PRIVACY POLICY Missed Appointment Policy: We attempt to make reminder calls for appointments, but it is ultimately your responsibility to remember appointments. We require that any cancellations or rescheduling needs be made at least 24-hours in advance. We will charge $30.00 per visit for missed or cancelled appointments with less than 24-hours notice. Assignment of Benefits: As a courtesy, our office will file your insurance claim. Complete insurance information for primary and secondary insurance coverage must be provided, including referral forms from other providers and all identification and benefit cards/documents required for claim accuracy. Our office will call your insurance provider to verify coverage but this does not guarantee coverage for or payment of services. Co-payments are due at the time of service. Deductible and Co-insurance amounts applied to the claim will be due from the patient. Please read and sign below: I understand and agree that health and accident insurance policies are an agreement between my insurance carrier and me. Furthermore, I understand that Austin Kinesiology and Chiropractic will prepare the necessary forms to assist me in collecting from my insurance company. However, I clearly understand and agree that payment for all services rendered to me is my responsibility. It is also my understanding that any amount that the insurance does not cover is my responsibility. Payment is due in full, regardless of the outcome of any litigation or settlements pertaining to my claims. I also understand that if I terminate or suspend care and treatment, any fees outstanding for professional services will be immediately due and payable. I am responsible to know what, if any, insurance coverage/benefits I have. I hereby assign all health care benefits and insurance payments to which I am entitled to Austin Kinesiology and Chiropractic. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. Patient Informed Consent: While the risks associated with chiropractic and physical therapy are small, they do exist and I will discuss those risks with my doctor. Associated risks include, but are not limited to: sprain/strain injuries, pain, discomfort, stroke, allergic reaction, and headache. If I have any medical conditions that increase the risk of treatment, I will inform the doctor. I also recognize that chiropractic and physical therapy may involve the touching of my body by a doctor or other members of the clinic's professional staff and that full or partial disrobing (gowns are provided) may be required to facilitate such care, all of which is expressly consented to by me. I acknowledge that I have had the opportunity to and will in the future ask my doctor about the potential risks involved with any aspect of my treatment. I will also be honest in giving the doctor feedback regarding each treatment and therapy session. Patient Privacy: As required by federal and state law, Austin Kinesiology and Chiropractic has made available, in writing, the clinic s policy regarding protection of private information and health care records. This written policy is publicly posted in the office and a copy is available to me for my records. I may request a copy of this at any time, and may revoke in writing certain permissions contained within this policy. Signature of Patient or Guardian Date

7 NON-RESCINDABLE LETTER OF PROTECTION This agreement is between (patient), Austin Kinesiology and Chiropractic, and any third-party involved in the accident on (date). I instruct my insurance company, personal injury protection, insurance settlement, attorney, or other payor to pay for services provided by Austin Kinesiology and Chiropractic directly to and in the name of Jeremy T. Bryson, DC. Furthermore, claims shall be paid in accordance with Article in a timely manner, not to exceed 30 days upon receipt of each claim. I instruct my attorney to pay in full any outstanding monies due my health care provider at the time of settlement with any liability claim that may result from this case. My attorney shall not withhold any portion of the amount due to my doctor under this agreement to offset attorney s fees, which my attorney now or hereafter may claim to be owed by me. I instruct my attorney to pay my doctor immediately upon settlement, by way of issuance of a separate draft made payable to Jeremy T. Bryson, DC. I instruct any third party individual or insurance carrier that may be liable, to pay my doctor directly for any outstanding medical bills which are the result of this accident. If payment is not made until the time of settlement, I instruct the third party to issue a separate draft to be payable to Jeremy T. Bryson, DC for the medical bills. I understand and acknowledge that all charges incurred by me are my responsibility regardless of any settlement made by a third party. I am instructing and agreeing to the above conditions as a safeguard to the doctor s right to collect payment. I understand that the doctor/clinic has the right to expect good faith payments on my account and that full payment is being deferred only until a third party settlement occurs. If a settlement does not occur within a reasonable amount of time, I agree to make other arrangements to pay my account in full. Patient or Guardian s Signature Date Doctor Signature Date

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