Intrinsic Chiropractic Center offers our patient forms online so they can be completed it in the convenience of your own home or office.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Download the necessary form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/NP_Form_Pg_1.pub
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/NP_Form_pg2.pub
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/HIPPAform.doc
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/EHRintake.doc
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/consenttreatxray.doc
https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/assignmentfinancial.doc
Name: _________________________Home Phone:_________________
Cell Phone:____________
Address: _____________________________ ____
City/State/Zip:___________________________
D.O.B.___________ _Age:_______Who may me thank for referring You?____________________
Is this for the whole family? Family: ______ Self: ________ Medicare Yes/No Car Accident Yes/No
Primary reason for consulting our office:________________________________________________
Occupation: _________________________________ Employer: ____________________________
Sex: M / F Single / Married / Divorced / Widowed Spouse's Name: _________________________
Name and Ages of Children: __________________________________________________________
Email: ______________________________________ Social Security Number: ________________
Your hobbies/interests/activities: ______________________________________________________
Do you exercise? NO / YES How often?_______________ What type: ________________________
Rate your diet: Healthy Average Poor Do you use supplements YES NO ____________________
Alcohol: Never / Rare / Moderate / Daily
Smoker? NO / YES ____ # Packs/day since year: ___ Past Smoker? NO / YES
What is the reason for consulting our office ?
___ Symptom Relief ___ Maintaining Your Current Level of Health ___ Optimum Wellness
Previous chiropractic care? YES / NO If yes, Dr.'s Name _____________________ Last Visit ____
Other doctors you are currently seeing: _________________________________________________
Current medications: ________________________________________________________________
Over the counter drugs taken in the past 3 months: ________________________________________
List all surgeries: ___________________________________________________________________
_________________________________________________________________________________
List all accidents and falls: ___________________________________________________________
_________________________________________________________________________________
Health is the most valuable asset in the world for you and your family. Healing includes taking responsibility for that health. Aspects of this responsibility are attending health workshops, following your care plan and meeting your financial obligations. Chiropractic is not a treatment nor a cure for any disease. The goal of chiropractic care is for restoration and maintenance of full function and communication within the body, from the brain to every cell in the body so that you may express full potential for life and healing.
Intrinsic Chiropractic Center, Dr. Jodi Kinney, 100 W. Veterans Hwy. Jackson, NJ 08527 (732) 833-9000
Page 1
Patient's Name____________________________________________________Date______/______/______
***If you are NOT experiencing ANY symptoms, please go to Section B: Health History***
Section A: Current Problem Please answer the following questions regarding your current problem:
Please mark on the picture, where you have any problems.
Date of Onset: ___________ Cause of Condition (if known)_____________________
How often during the day do you experience this?
___ 0-25% ___ 25-50% ___ 50-75% ___ 75-100%
Describe the pain: ___ sharp ___ dull ___ achy ___ stiff ___ shooting ___ burning ___ spasm
How severe is this problem? No Pain 1 2 3 4 5 6 7 8 9 10 Extreme
Since the onset, is the pain? ___ worse ___ better ___ same ___on & off
Is there anything that makes it worse? ___ standing ___ sitting ___ lying down ___ motion
Is there anything that makes it better? ___ standing ___ sitting ___ lying down ___ motion
Is this problem? ___ Better or ___ Worse ___ AM or ___ PM ___ Neither
Are any systems involved? ___ Digestive ___ Cardiovascular ___ Respiratory ___ Elimination ___ Reproductive
Does the pain cause you to? ___ Lose sleep ___ Be short tempered ___ Miss work ___ Miss play ___ Lose focus
What has this problem kept you from enjoying? ___________________________________________________
Have you had a similar condition in the past? Y N If yes, explain: ___________________________________
What treatment(s) have you already had for this problem?
Medication Surgery Physical Therapy Chiropractic None Other:__________________
What was the outcome of this treatment?_______________________________________________________________
Any other facts about your current problem or pain: ____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________
Is there any chance you could be pregnant? YES NO Date of last menstrual period:_____________________________
Section B: Health History (Please check if you have had or are currently experiencing any of the following:)
Anxiety Anemia Arthritis Thyroid Problems Bowel Problems
Cancer HIV/AIDS Tuberculosis High Blood Pressure Heart Trouble
Diabetes Hepatitis Insomnia Venereal Disease Muscular Dystrophy
Epilepsy Dizziness Convulsions Multiple Sclerosis Rheumatic Fever
Neuritis Asthma Scarlet Fever Digestive Problems Sinus Trouble
Allergies Backaches Numbness Frequent Colds Nervousness
Stroke Depression Headaches Cold Hands/Feet Restless Sleep
Ulcer Irritability Impulsivity Low Pain Threshold Fibromyalgia
Hernia PMS Bruising German Measles Osteoporosis
Nausea Swelling Mood Swings Chronic Fatigue Syndrome Infertility
Describe other details about YOUR Past Medical History:__________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Section C: Family History (Your Blood Relatives Only)
‡ Diabetes Heart Disease Cancer Thyroid Problems Stroke Multiple Sclerosis
‡ Other: _________________________________________________________________________________________
Patient/Guardian Signature: _______________________________________Date:_______________________________
Intrinsic Chiropractic Center
Confidential New Member Information
Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.
________________________________________________________________________
100 W. Veterans Highway
Suite 7
Jackson, NJ 08527
(732) 833-9000
Consent to Professional Treatment
The patient certifies that all information provided to this office is true and correct, to the best of their knowledge. The patient grants their consent to this office and its staff to render treatment as deemed necessary by the attending physician. If the patient is a minor child, under the age of eighteen (18) at the date of treatment, I hereby stipulate that I am the legal guardian of the child, and grant my consent for the treatment of the child as provided for herein. The patient may refuse treatment at any time.
_________________________________ _______________
Signature Date
Consent to Perform and Interpret X-rays
The patient consents to the performance of x-rays as deemed necessary by the attending physician of this office. The patient acknowledges that certain risks are associated with x-rays. The patient, hereby states that they have no known limitations that would forbid the taking of x-rays.
The patient further agrees that this office may seek outside interpretation of patient x-rays by a qualified professional not employed by this office. The patient agrees to any additional fees associated with this service and assigns benefits to be paid directly to that professional by your third-party payor.
_________________________________ _______________
Signature Date
Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.
________________________________________________________________________
100 W. Veterans Highway
Suite 7
Jackson, NJ 08527
(732) 833-9000
Assignment of Benefits and Release of Records
The patient hereby assigns benefits to be paid directly to this provider by all of their third party payors. This assignment is irrevocable. Failure to fulfill this obligation will be considered a breach of contract between the patient and this office.
The patient authorizes this office to release any information required by a third party payor necessary for reimbursement of charges incurred.
_________________________________ _______________
Signature Date
Financial Obligation and Appointment Policy
The patient accepts full financial responsibility for services rendered by this practice. Payment in full is required for all services rendered at the time of visit, unless alternative arrangements have been agreed to in advance. Patient accepts full responsibility for any fees incurred, including but not limited to legal fees, collection agency fees, and any and all other expenses incurred in the collection of past due accounts. Patient should direct any questions regarding this financial obligation and appointment policy to the clinic manager or physician.
The patient further authorizes the practice to retain credit card, debit card, checking account or other payment source(s) supplied by patient to the practice for current and future charges, when incurred.
_________________________________ _______________
Signature Date
Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.
________________________________________________________________________
100 W. Veterans Highway
Suite 7
Jackson, NJ 08527
(732) 833-9000
Patient Health Information and
Privacy Policy
This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient's rights concerning those records. You must read and consent to this policy before receiving services. A complete copy of the Health Information Portability and Accountability Act (HIPAA) is available here: Final Rule as seen in Federal Register 2/20/2003
1. The patient understands and agrees to allow this office to use their PHI for the purpose of treatment, payment, health care operations and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment.
2. The patient has the right to examine and obtain a copy of their health records at any time and request corrections. The patient may request to know what disclosures have been made, and submit in writing any further restrictions on the use of their PHI. This office is not obligated to agree to those restrictions.
3. The patient's written consent shall remain in effect for as long as the patient receives care at this office, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services.
4. This office is committed to protecting your PHI and meeting its HIPAA obligations: Staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures.
5. Patients have the right to file a formal complaint with our privacy official about any suspected violations.
6. This office has the right to refuse treatment if the patient does not accept the terms of this policy.
_________________________________ _______________
Signature Date
Dr.
Phone- (732) 833-9000
Fax-(732)833-9932
Electronic Health Records Intake Form
In compliance with Medicare requirements for the government EHR incentive program
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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)
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Dosage and Frequency (i.e. 5mg once a day, etc.) |
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Do you have any medication allergies?
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Medication Name |
Reaction |
Onset Date |
Additional Comments |
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□ 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:________________
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For office use only Height: _________ Weight:____________ Blood Pressure:______ /______ |