Download Lion`s Head Chiropractic and Wellness Clinic

2 Helen St., Lion’s Head, ON
(519)793-3092
Dr. Ian J. Quist
Name:
Phone (H):
File #: _____________
Date:
Sex:
F
M
Date of Birth (MM/DD/YYYY):
Mailing Address:
City/Postal Code:
Occupation/Employer:
Previous Chiropractor:
E-mail:
Phone (W):
Phone (C):
Marital Status:
If you have children, what are their ages?
Current health complaints/reasons for consulting our office:
1.
Pain
/10 (10 being the worst)
Pain
/10 (10 being the worst)
2.
Who can we thank for referring you?
Have you had similar problems in the past? If so, for how long?
Do you have a father, mother, brother, sister or children with similar problems? If so, who?
Have you seen other doctors for this problem? If so, who and what was the treatment?
Please list ALL surgeries:
Please list ALL medications that you currently take:
Who is your Medical Doctor?
Have you ever been diagnosed with cancer? If so, what kind?
Please list any other health concerns:
Do you: SMOKE /day ALCOHOL mild/moderate/severe CAFFEINE mild/moderate/severe
Please list your family history of sickness and disease:
Is there any chance that you could be pregnant?
YES
NO
INFORMED CONSENT TO CHIROPRACTIC ADJUSTMENTS AND CARE
I hereby request and consent to the performance of Chiropractic Care. This includes
Chiropractic Adjustments and other Chiropractic Procedures. This treatment may include xrays by Dr. Ian J. Quist. I understand and have been informed, as in all health care, in the
practice of Chiropractic there are some very slight risks to treatment, including but not
limited to rib fracture, muscle strain or stroke. I do not expect the Doctor to be able to
anticipate and explain all risks and complications and I wish to rely on the Doctor to exercise
judgment during the course of this procedure based upon the facts then known, is in the best
interest. I have had an opportunity to discuss with Dr. Quist the nature and purpose of the
Chiropractic Adjustment and other procedures. I have read the above consent. I have also
had an opportunity to ask questions about its content, and by signing below I agree to the
above named procedures. I intend this consent to cover the entire course of treatment for my
present condition and for future condition(s) for which I seek treatment.
CONSENT FOR PERSONAL INFORMATION
I understand that to provide me with Chiropractic goods and services, Dr. Ian J. Quist will
collect some personal information about me (e.g. telephone number, address, date of birth,
health history, etc.). I understand that Dr. Ian J. Quist has a privacy policy about the
collection, use and disclosure of personal information. I understand that I may receive notice
when it is time to review whether I need new goods or services; I may receive newsletters and
other informational mailings from Dr. Ian J. Quist. I agree to Dr. Ian J. Quist collecting, using
and disclosing personal information about me as set out above and in Dr. Ian J. Quist’s Privacy
Policy.
CONSENT FOR X-RAYS
I have been informed of the risk of radiological studies. To the best of my knowledge I
am not pregnant and Dr. Ian J. Quist has my informed consent to take what he
considers clinically necessary x-rays.
I understand the Informed Consent for Chiropractic care and x-rays and the Personal
Information material as stated above. I also understand that I am financially responsible for
all services that are rendered by Dr. Ian J. Quist of the Lion’s Head Chiropractic Clinic.
Patient Name (Please Print): ___________________ Patient Signature:____________________
Witness (Please Print): ________________________ Witness Signature: ____________________