New Patient Forms

New Patient Forms

New Patient Forms

New Patient Forms

New Patient Form

Patient Information
Name
Date
Address
City
State
Zip Code
Cell Phone
Home Phone
Email Address
Social Security #
Driver's License
Birthdate
Age
Sex
Marital Status
Number of Children
Occupation
Employer
Business Phone
Address
City
State
Zip
Name of Spouse (Or parent, if minor)
Address
City
State
Zip
Person Responsible for Account
Address
City
State
Zip
Referred By
Have you had chiropractic before?
When?
Do you have health insurance?
What company?
Policy #
Group #
Insured Name
Date of Birth

Nearly all insurance policies provide chiropractic coverage, but benefits vary. Therefore, although we will fill out the insurance forms, the patient is personally responsible for payment of services rendered. We do accept certain insurance assignments, but all arrangements must be approved in advance.


FEES ARE PAYABLE WHEN SERVICES ARE RENDERED UNLESS SPECIAL ARRANGEMENTS HAVE BEEN MADE IN ADVANCE.

Check Type(s) of Insurance Coverage:
Signature
Patient Admittance Form
Today's Date
Name
List of Complaints:

What positions or movements aggravate your complaints (Sitting, standing, lying down, etc)
Describe the physical movements and actions relative to your occupation:
List any doctors consulted for this condition(s):

Reviews of Systems
Patient Name
Please enter: 1 (Previously); 2(Presently) in front of all of the following signs and symptoms. A complete history and understanding of your health status will facilitate care.
​​​​​​​
General Symptoms

Headache
Dizziness
Convulsions
Loss of Sleep
Fatigue
Loss of Weight
Numbness or pain in arms/legs/hands
Allergy
Others
Gastro-Intestinal

Poor Digestion
Belching or Gas
Nausea
Pain over Stomach
Constipation
Diarrhea
Colon Trouble
Hemorrhoids (Piles)
Others
Eye Ear Nose Throat

Poor Vision
Deafness
Ear Noises
Nose Bleeds
Sore Throat
Asthma
Frequent Colds
Sinus Trouble
Others
For Women Only

Painful Periods
Excessive Flow
Irregular Cycles
Hot Flashes
Cramps or Backache
Miscarriage
Vaginal Discharge
Pregnant at this time
Last pap?
Others
Muscle & Joints

Weakness
Stiff Neck
Backache
Swollen Joints
Nose Bleeds
Tremors
Foot Trouble
Pain Between Shoulders
Hernia
Spinal Curvature
Cardio-Vascular

Slow Heart
High Blood Pressure
Low Blood Pressure
Swelling of Ankles
Poor Circulation
Varicose Veins
Strokes
Blood Type
Others
Skin or Allergies

Bruise Easily
Dryness
Sensitive Skin
Hives or Allergy
Eczema
Others
Respiratory

Chronic Cough
Spitting Blood
Spitting Phlegm
Difficulty Breathing
Others
Genito-Urinary

Frequent Urination
Painful Urination
Blood in Urine
Kidney Infection
Bed Wetting
Inability to Control Urine
Prostate Trouble
Others
Habits

Smoking
Alcohol
Coffee
Exercise
Does your immediate family have a history of health conditions such as heart, diabetes, kidney, cancer, stroke, back, and osteoporosis? Please explain.
Have you had any of the following?
OPERATIONS AND PROCEDURES
Accidents or Falls: Auto, etc.
Broken bones or Dislocations:
Have you ever had a spinal tap or spinal injection?
Have you ever been knocked unconscious?
Do you suffer from any condition other than that for which you are now consulting us?
If so, what is that condition?
If you are presently taking any medication, either prescription or over-the-counter, list them and their dosages:
PROCEDURES
Appendectomy
Back Operation
Breast
Gall Bladder
Hernia
Ovary/Uterus
Prostate
Rectal Surgery
Sinus
Stomach
Thyroid
Tubes in Ears
Vaccinations
Other
Signed
Date
Authorization for Chiropractic Treatment

AUTHORIZATION FOR CHIROPRACTIC TREATMENT

I, the undersigned, a patient in this office, hereby authorize Dr. Albert C. Hoff, Jr. and Dr. Justin Hoff and whomever they may designate as their assistants, to administer such treatment as is necessary and perform the following therapy, adjustments and such additional therapy and procedures as are considered therapeutically necessary on the basis of findings during the course of said treatment.

I hereby certify I have read and fully understand the above Authorization of Chiropractic Treatment, the reasons why the above named treatment is necessary, its advantages and possible complications, if Dr. Albert C. Hoff, Jr. and/or Dr. Justin Hoff.

I also certify that no guarantee or assurance has been made as to the results that may be obtained.

Patient Name
Date
Signed

GENERAL RELEASE OF INFORMATION

I hereby authorize any hospital, physician or other person who has examined or attended me, to furnish to Rosemount Chiropractic or a representative thereof, any and all information with respect to any illness, medical history, consultation, prescriptions or treatment, and copies of all hospital or medical records. I hereby, authorize Rosemount Chiropractic to release to authorized person any and all records pertaining to my treatment in said clinic. A photocopy of this authorization shall be considered as effective and valid as the original. It shall remain effective until I revoked it with written authorization for revocation.

Date
Signed

ASSIGNMENT OF BENEFITS
​​​​​​​

I hereby assign all medical and/or surgical benefits, to include major medical benefits to which I am entitled, including Medicare, private insurance and other health plans to Rosemount Chiropractic​​​​​​​. This assignment is to be considered as valid as an original. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorized said assignee to release all information necessary to secure payment.

Date
Signed

PATIENT HEALTH INFO CONSENT FORM (PHI)

Concerning the privacy of your Patient Health Information, we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.

Date
Signed

CONSENT TO TREATMENT OF MINOR CHILD

I hereby authorize Dr. Albert C. Hoff, Jr., and Dr. Justin Hoff and whomever he may designate as his assistants, to administer treatment, as he so deems necessary to my son/daughter.

Child's Name
Date
Signed
admin none 7:45 AM - 11:00 AM 2:00 PM - 6:00 PM 2:00 PM - 6:00 PM 7:45 AM - 11:00 AM 2:00 PM - 6:00 PM 2:00 PM - 6:00 PM 6:30 AM - 9:30 AM Closed Closed Chiropractor # # #