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Chiropractic Case History/ Patient Information

Please print out the form after you have downloaded the following PDF. Fill out the form completely and fax it over to our office Fax: (317-585-9411) or scan to email back.

Click the PDF icon below to download our patient forms

SOCIAL HISTORY:

FAMILY HISTORY:

Parents:

FAMILY DISEASES

Tuberculosis

Diabetes

Stroke

Arthritis

Cancer

Asthma

Hay Fever

Kidney Disease

Liver Disease

Mental

Heart Disease

Lung Disease

Back Trouble

Bursitis

Constipation

Disc Problem

Emphysema

Epilepsy

Headaches

High Blood Pressure

Insomnia

Migraine

Nervousness

Neuritis

Neuralgia

Pinched Nerve

Scoliosis

Sinus Trouble

Stomach Trouble

Other

INFORMED CONSENT TO TREAT: I understand and am informed that, in the practice of chiropractic medicine there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. I understand that I may revoke this consent at anytime verbally or in writing to the doctor. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the procedures outlined by my doctor of chiropractic in my treatment plan. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

 

 

 

 

 

 

 

 

The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records.

 

Please read before submitting.

 

I understand that in order to continue to get one year of unlimited doctor visits, recommended lab tests and free shipping on my nutritional supplements, I must agree to purchase my doctor recommended nutritional supplements from the Hope For Parkinson's clinic.

 

I understand that any unopened supplements may be returned

for a full refund at any time.

 

I agree to purchase my doctor recommended nutritional supplements from the Hope For Parkinson's clinic as part of my commitment to one year of this program.