Aspen Chiropractic & Wellness

Transcription

1 WELCOME TO OUR OFFICE We are committed to providing you the best of care and are pleased to discuss our professional fees with you at any time. Please ask any questions you may have regarding our fees or your responsibility in complying with our financial policy and/or procedures. Co-payment/Cash: Payment is due when services are rendered. MasterCard, American Express, checks, and cash. We gladly accept Visa, Insurance Patients: Professional services are rendered and charged to your insurance on your behalf. Any services not covered by your insurance are ultimately your responsibility and may have to be paid by you at the time of service. Deductibles are the patients full responsibility. If you fail to keep your appointments or you discontinue care for any reason other than discharge by the Doctor, the bill is due and payable by you in full immediately, regardless of any insurance claims submitted. Our office accepts billing for Individual or Group insurance policies. Missed Appointments: A $25.00 fee will be charged to the patient for appointments cancelled without a 24-hour notice. Collection/Attorney Fees: I agree to pay all costs of a collection agency if necessary, not to exceed 25% of the principle to obtain payment in the event that legal action should become necessary to collect an unpaid balance due for medical services. I agree to pay reasonable attorney s fees or other such costs as the court determines proper. Limited release of Medical Information: I authorize Aspen Chiropractic & Wellness to make inquiries and to release any pertinent information to any insurance company, adjuster or attorney to facilitate collection under these circumstances. Assignment of Cause of Action: In the event that any insurance company or other third party obligated to make such payment to me or to Aspen Chiropractic & Wellness for the charges made for these services refuses to make such payment on demand, I hereby assign, transfer, and convey to Aspen Chiropractic & Wellness any and all cause of action that might exist in my favor against any such company or person. I authorize Aspen Chiropractic ic & Wellness to prosecute said action in my name or their name to collect fees due for care rendered and legal expenses, and to resolve said claims as they see fit. By signing this statement, I am agreeing to all above notices. Signature Date

2 General Information Aspen Chiropractic & Wellness Patient Information Thank you for choosing Aspen Chiropractic and Wellness. Please use black ink to fill out forms. Please don t hesitate to ask if you need assistance. Name: Date: S.S. # First M.I. Last Address: City: State: Zip: Birth date: / / Gender: Female Male Hm Ph: ( ) Cell Ph: ( ) Wrk Ph: ( ) Status: Single Married Widowed Separated Divorced Minor Patient Employer/School: Occupation: Employer/School Address: City: State: Zip: Spouse/Parent s Name: Employer: Wrk Ph: ( ) Person to contact in case of emergency: Ph: ( ) to patient: _ Insurance Information Who is responsible for this account: to Patient: Insurance Company: Policy #: Group#: Is patient covered by additional insurance? Yes No If yes which Insurance Company: Policy #: Group#: Consent to Treat By signing below I am indicating that the above information is correct. I also give the doctors and staff at Aspen Chiropractic and Wellness permission to treat my condition as deemed necessary. Patient Signature / Guardian Signature Date

3 Past Medical History (Female) Age Menses started: Last Menstrual period (date): Number of days between periods: is your cycle normal from month to month Yes No Circle what best describes changes: [Intervals between cycles] [Flow heavier or lighter] [PMS symptoms worsening] [Spotting before or after cycles] If none above apply; explain changes Date of last PAP smear: any history of abnormal PAP smears? Yes No Outcome Have you had a mammogram? Yes No Date Normal: Yes No if no explain Have you had a Bone Density Scan? Yes No Date Findings: [Normal] [Osteopenia] [Osteoporosis] Have you had a colonoscopy? Yes No Date Findings: Have you had an endometrial Ablation Yes No Have you had a Hysterectomy? Yes No --- If so, you still have your ovaries? Yes No Are you interested in bio-identical hormones? Yes No Exercise Routine Number of days per week Do you have an eating disorder? Yes No Bulimia Anorexia Overeating Major Hospitalization/accidents/serious illnesses Surgical History: Gallbladder Appendix T & A Hysterectomy Ovary removal: R/L Other: Is there any Immediate Family History of any of the following? FMH: Cancer Diabetes High Blood Pressure Stroke Heart attack High Cholesterol Stress Factors: Work s currently Flow infections Yeast BV Other Ectopic pregnancies past currently Recurrent UTI s past currently Ovarian cysts past currently STD s past currently Uterine fibroids past currently Pelvic Inflammatory past currently Disease (PID) Is there any Family History of any of the following? (Please check) Breast Cancer Uterine Cancer Ovarian Cancer

4 Aspen Wellness Center Women Evaluation Women Intake Form Name: Today s Date: Allergies to medications? Yes No What is the reason for your visit today? C/C: Patient here for a wellness evaluation, and presents with the following symptoms: Circle the symptoms that are applicable to you: Hot flashes Swollen breasts/lump Loss of muscle Night sweats Frequent Headaches Muscle weakness Sleep issues Vaginal dryness Dry skin/skin thinning/fingernails breaking Anxiety Nervousness Depression Memory loss/brain fog Muscle and joint pain Weight gain difficulty losing weight cellulite Get sick more often or increasing allergy symptoms Mood swings Feeling overwhelmed Low energy Hair loss/facial hair Restless Leg Syndrome Work outs are a struggle or longer to recover Heavy menstrual flow Painful intercourse Bloating frequent episodes of constipation or loose stools Frequent episodes of Constipation or loose stools Low libido or Inability to have orgasm Feeling cold often Food cravings sweets carbs - salt Urinary urgency or frequency Have you been told you have any type of medical condition/disorder? Yes No If so what type of condition? Depression/Anxiety Diabetes Heart disease High blood pressure High Lipids Asthma Blood Clots Migraines Liver Disease DES exposure Seizure other Are you under treatment for it? Yes No If so what type of treatment (circle applicable) Medication Physical Therapy Counseling Acupuncture Other

5 List current Prescriptions and dose: Medications Name Dose (You may attach list) Herb Products/dietary supplements: (You may attach list) Are you currently on any type of Hormonal Replacement Therapy (HRT)? Yes No If so, what type and what dosage are you currently taking: _

6 Getting To Know You Name: Whom may we thank for referring you? Where are you from? Are you? Married Single Partner What is your Occupation? Do you have any children? Yes No Girl(s) Boy(s) What are your hobbies(s)? I have received a copy of the Notice of Privacy Practices. Patient Signature Date

7 Others Involved in My Healthcare Patient Name: _ ID Number: You, Dr. Shane McCall, MAY discuss all aspects of my healthcare with: As the patient, you may also request that any part of your Private Health Information (PHI) not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must be in writing and state the specific restriction requested and to whom you want the restriction to apply. Your physician is not required to agree to a restriction that you may request. If your physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. If your physician does agree to the requested restriction, we may not or disclose your PHI in violation of that restriction unless it is needed to provide emergency treatment. With this in mind, please discuss any restriction you wish to request with your physician. You, Aspen Chiropractic & Welness, MAY NOT discuss any aspect of my health care with the following person/people, unless it is needed to provide emergency treatment. Signature of Patient or Legal Representative Date: (You have the right to rescind any part of this authorization with written notice.)