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PATIENT REGISTRATION FORM
PATIENT INFORMATION
Date:_______________________________________________
Last Name: _________________________________________ First Name: ________________________________________
Address: ________________________________________________________ Apt #: _________________________________
_________________________________________________________________________________________________________
City
State
Zip Code
Home Phone (__________)___________________________ Mobile Phone: (__________) ___________________________
Work Phone: (__________) ___________________________ Ext: _____________________
E-Mail Address :_________________________________________________________________________________________
Sex:
M
F
Age: _____ Date of Birth: _____/ _____/ _____
Single
Married
Divorced
Social Security Number : _________-_______-_________ Driver’s License Number: ______________ State: _______
EMPLOYMENT INFORMATION
Employer: _______________________________________ Occupation: __________________________________________
Employer Address: ________________________________________________________________
FAMILY INFORMATION
Name Of Spouse: _______________________________ Phone Number (__________) ____________________________
Employer: ______________________________________ Occupation: ___________________________________________
EMERGENCY CONTACT
Name: _______________________ Phone Number: (_______) _______________ Relationship: _____________________
MEDICAL PHYSICIAN INFORMATION
Name Of Your Medical Doctor:___________________________________________________________________________
Phone Number: (__________) ____________________ Location: _______________________________________________
ACCIDENT INFORMATION
Is condition due to an accident?
Type of Accident?
Auto
Yes
Work
No
Date:________________________________
Home
Other: ______________________________
To whom have you made a report of your accident? (Circle all that apply)
Auto Insurance
Employer
Do you have Health Insurance?
Insured Party?
Yes
Self
Workers’ Comp.
Other: ______________________________
No
Spouse
Other: ______________________________
INSURANCE COVERAGE INFORMATION
Only complete the type of insurance that pertains to your condition
Health Insurance
Insurance Carrier Name: _________________________________ Phone Number: (__________) ____________________
Policy Holder Name: _____________________________________ Policy Number: _______________________________
Group Number: __________________________________________
Personal Injury/ Auto/ Vehicular Accident
Do you have “Medical Payment” (MedPay) on your Auto Policy?
Yes
No
Your Insurance Carrier Name: ___________________________ Claim Number: ________________________________
Name of other people in the car with you:
1. _____________________________________
3. _____________________________________
2. _____________________________________
4. _____________________________________
Third Party Payer
Third Party (Person at Fault) Name: _________________________ Phone Number: (_________) _________________
Their Insurance Carrier: _________________________________________________________________________________
Adjuster Name: ____________________________________________ Claim Number: _____________________________
Workers Compensation Injury
Employer: ________________________________________________ Phone Number: (_________) ___________________
Address: ________________________________________________________________________________________________
Date of Accident: ________________________________________ Time: _________________________________________
Workers Compensation Carrier: _________________________ Carrier Phone Number: (_________)_______________
Adjuster Name: _________________________________________________________________________________________
Claim Number: _________________________________________ Policy Number: _________________________________
ASSIGNMENT AND RELEASE
I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Scott Warren, DC, QME/ Warren Chiropractic Inc. all
insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by
insurance. I herby authorize Dr. Warren to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance
submissions.
___________________________________________________
Patient Signature
Warren Chiropractic, Inc.
_______________________________
Date
1650 Lead Hill Blvd. Ste 600 Roseville, CA 95661
Patient Health History
Symptoms
Name: __________________________________ Date: ___________________________________
Please check any symptoms you have below.
Arm Pain
Cancer
Chest Pain/Conditions
Cold Extremities
Constipation
Cramps
Depression
Diabetes
Digestion Problems
Dizziness
Ears Ring
Elbow Pain
Eye Pain/Difficulties
Fatigue
Frequent Urination
Hand Pain
Headache
High Blood Pressure
Irregular Heartbeat
Kidney Infection
Kidney Stones
Knee Pain
Leg Pain
Loss of Balance
Low Back Pain
Mid Back Pain
Neck Pain or Stiffness
Nervousness
Numbness/ Tingling
Polio
Poor Posture
Pregnant
Prostate Trouble
Shortness of Breath
Shoulder Pain
Sinus Infection
Sleep Problems/Insomnia
Stroke
Swelling of Ankles
Swollen Joints
Thyroid Condition
Ulcers
Varicose Veins
Wrist Pain
Other _______________________
Please identify on the body diagram below where
you are having symptoms using the appropriate
letter and number to identify your symptoms.
P= Pain B= Burning
N= Numbness/Tingling
R= Radiating
T= Tenderness
Please rate each symptom using a scale of 0-10.
(Please write the number next to the symptom)
0-1 Minimal- The pain is mild and an
annoyance.
2-3 SlightThe pain is tolerable and can
interfere with daily activities.
4-6 Moderate- The pain cannot be ignored and
interferes with daily activities
or work.
7-8 Marked- The pain is debilitating.
9-10 SevereThe pain is my worst imaginable
and stops me from all activities.
Warren Chiropractic, Inc
Scott Warren, D.C., QME
1650 Lead Hill Blvd Ste 600
Roseville, CA 95661
Office (916) 784-2454
Fax (916) 784-0454
INFORMED CONSENT REQUIREMENT
&
NOTICE OF PRIVACY POLICY
Dear patients:
Please be advised that the Board of Chiropractic Examiners (BCE) recently
adopted informed consent requirements; California Code of Regulations, Title 16,
Div. 4, Article 2, Section 319.1 provides that:
INFORMED CONSENT:
(a) A licensed doctor of chiropractic shall verbally and in writing inform each
patient of the material risks of proposed care. ”Material” shall be defined
as a procedure inherently involving known risk of serious bodily harm.
The Chiropractor shall obtain the patient’s written informed consent prior
to initiating clinical care. The signed written consent shall become part of
the patient’s record.
I_____________________________________________________, do hereby give my consent to
the performance of conservative noninvasive chiropractic treatment to the joints and soft
tissues. I understand that the procedures may consist of manipulations/adjustments
involving movement of the joints and soft tissues. Physio-therapy and exercises may
also be used.
Although spinal and extremity manipulation/adjustment is considered to be one of the
safest, most effective forms of therapy for musculoskeletal problems, I am aware that
there are possible risks and complications associated with these procedures as follows:
Soreness, bruising, dizziness, physio-therapy burns, and serious bodily harm.
I have read or had read to me the above explanation of chiropractic treatment. Any
questions I have regarding these procedures have been answered to my satisfaction
prior to my signing this consent form. I have made my decision voluntarily and freely.
To attest to my consent to these procedures, I hereby affix my signature to this
authorization for treatment. I also understand my information will be held private
until I sign a release per Health Insurance Portability and Accountability Act
(HIPAA).
__________________________________________
Signature of Patient
__________________________________________
Signature of Parent or Guardian (if for a minor)
___________________________________________
Signature of Witness
____________________________
Date
____________________________
Date
___________________________
Date