Download Assignment and Release (insured patients)

Date______________ File No:___________
Welcome to Kobler Chiropractic and Acupuncture! We look forward to working with your family to
achieve optimum health. A patient’s health is not based on symptoms or lack of symptoms. For instance,
a tooth is not considered healthy when it has decay even though there is no pain felt. A dentist checks for
these “painless” cavities just as a chiropractor checks for spinal misalignment to maintain spinal health.
Chiropractic does not cure any disease or treat symptoms alone. Rather, our chiropractic analysis will
focus on removing nervous system interference, caused by physical, chemical, and/or emotional stressors,
allowing the child’s body to properly express health. To help us serve you better, please complete the
following:
Patient Information
Name:
Last
First
MI
Mailing Address:________________________________________________City_____________________ State____ Zipcode__________
Phone #(H)____________________________ (C)_______________________ (Other)
Email address:_______________________________________________________________________________
Sex:  Male
Date of Birth:
Marital Status:
 Single
 Married
 Divorced
Occupation:
 Female
SS#:
 Widowed
 Separated
 Minor
Employer:
Employer Address:
Phone:
How did you hear about our practice?
Emergency contact:
Phone #:
Name:
Relation:
(H)
(W)
(Other)
Accident Information
Is this visit due to an accident?
Has it been reported?
 Yes
 Yes
 No
 No
If yes, what type?  Auto  Work  Other
If yes, to whom?
Financial Information
Name of person responsible for this account:
Relationship to patient (if other than self):
Phone #
Do you have health insurance?
 Yes  No
Name of Carrier:
Do you have secondary insurance?
 Yes  No
Name of Carrier:
PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)
Assignment and Release (insured patients)
I certify that I (or my dependent) have insurance coverage with
and I AUTHORIZE, REQUEST AND ASSIGN
MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE INSURANCE BENEFITS
OTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby
authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in
order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.
SIGNATURE (X)
DATE
Health History
Who is your primary care physician? (doctor and/or practice)
Please check to indicate if you are currently experiencing any of the following conditions:
 Neck Pain/Stiffness  Pins/Needles in Arms  Light Bothers Eyes  Sudden Weight Loss  Nausea
 Back Pain/Stiffness  Pins/Needles in Legs  Depression
 Loss of Taste
 Cold Feet
 Arm/Hand Pain
 Fatigue
 Nervousness
 Loss of Memory
 Chest Pain
 Leg/Knee Pain
 Sleeping Difficulties  Tension
 Jaw Problems
 Fever
 Headaches
 Loss of Smell
 Cold Sweats
 Constipation
 Fainting
 Dizziness
 Allergies
 Stomach Problems  Shortness of Breath
 Asthma
 Blurred Vision
 Night Pain
 Bowel/Bladder Changes
Please check to indicate if you have ever had any of the following:
 Aids/HIV
 Alcoholism
 Allergy Shots
 Anemia
 Anorexia
 Appendicitis
 Arthritis
 Asthma
 Bleeding Disorders
 Breast Lump
 Bronchitis
 Bulimia
 Cancer
 Cataracts
 Chemical Dependency
 Chicken Pox
 Diabetes
 Emphysema
 Epilepsy
 Fractures
 Glaucoma
 Goiter
 Gonorrhea
 Gout
 Heart Disease
 Hepatitis
 Hernia
 Herniated Disc
 Herpes
 High Cholesterol
 Kidney Disease
 Liver Disease
 Measles
 Migraines
 Miscarriage
 Mononucleosis
 Multiple Sclerosis
 Mumps
 Osteoporosis
 Pacemaker
 Parkinson’s Disease
 Pinched Nerve
 Pneumonia
 Polio
 Prostate Problems
 Prosthesis
 Psychiatric Care
 Rheumatoid Arthritis
 Rheumatic Fever
 Scarlet Fever
 Other
 Stroke
 Suicide Attempt
 Thyroid Problems
 Tonsillitis
 Tuberculosis
 Tumors/Growths
 Typhoid Fever
 Ulcers
 Vaginal Infections
 Venereal Disease
 Whooping Cough
Are you currently under drug and/or medical care?  Yes  No If yes, explain
Please list any medications you are currently taking:
Please list any surgeries and/or hospitalizations you have had (type & date):
Please list any allergies:
Please list any supplements you are currently taking (vitamins/herbs/minerals):
Is there a family history of any of the following conditions? (indicate family member including parents, grandparents & siblings)
 Heart Disease
 Cancer
 Diabetes
 Arthritis
Do you exercise:  Frequently
 Moderately
Do your work activities mostly involve:
Do you sleep on your:
 Back
 Other
 Sitting
 Side
 Occasionally
 Standing
 Stomach
 None
 Light Labor
 Heavy Labor
Do you use a cervical pillow?  Yes
 No
What is your daily/weekly intake of the following:
Caffeine
cups/day
Alcohol
drinks/week
Cigarettes
packs/day
I certify that the above questions were answered accurately. I understand that providing incorrect information can be dangerous to my
health.
SIGNATURE (X)
DATE
:
TERMS OF ACCEPTANCE
When a person seeks chiropractic health care and we accept a patient for such care, it is essential for
both to be working towards the same objective. Chiropractic has only one goal. It is important that each
patient understand both the objective and the method that will be used to attain it. This will prevent any
confusion or disappointment.
Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of
vertebral subluxation. Our chiropractic method of correction is specific adjustment of the spine.
Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease or
infirmity.
Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which
causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a
lessening of the body's innate ability to express its maximum health potential. We do not offer to diagnose
or treat any disease or condition other than vertebral subluxation. However, if during the course of a
chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you.
If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the
services of a health care provider who specializes in that area. Regardless of what the disease is called, we
do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY
PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate
wisdom. Our only method is specific adjusting to correct vertebral subluxations.
CONSENT TO CARE
I do hereby authorize the doctors of Kobler Chiropractic and Acupuncture LLC to administer such care
that is necessary for my particular case. This care may include consultation, examination, adjustments,
or any other procedure which is advisable and necessary for my health care. l further understand that a
fee for services rendered will be charged and that l am responsible for this fee whether results are
obtained or not.
I also understand any sum of money paid under assignment by any insurance shall be credited to my
account, and l shall be personally liable for any and all of the unpaid balance to the doctor.
I ________________________, have read, understand, and hereby request chiropractic care based on the
terms of acceptance and the consent to care.
Signature: _____________________________________________ Date: _______________________
signature of parent or guardian if minor
Electronic Health Records Intake Form
In compliance with requirements for the government EHR incentive program
First Name:_________________________
Last Name:_________________________
Email address: __________________________@_________________________
Preferred method of communication for patient reminders (Circle one): Email / Phone / Mail
DOB: __/__/____
Gender (Circle one): Male / Female
Preferred Language: _______________
Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked
CMS requires providers to report both race and ethnicity
Race (Circle one): American Indian or Alaska Native / Asian / Black or African American / White
(Caucasian) / Native Hawaiian or Pacific Islander / Other / I Decline to Answer
Ethnicity (Circle one): Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer
Are you currently taking any medications? (Please include regularly used over the counter medications)
Medication Name
Dosage and Frequency (i.e. 5mg once a day, etc.)
Do you have any medication allergies?
Medication Name
Reaction
Onset Date
Additional
Comments
I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a
result of the nature and frequency of chiropractic care.)
Patient Signature: __________________________________________Date: ________________
For office use only
Height: _________
Weight:____________
Blood Pressure:______ /______