Welcome to our office!
Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care.
CONFIDENTIAL PATIENT INFORMATION
About the Spouse
Assignment of Benefits/Authorization of Direct Payment to Doctor
I IRREVOCABLY ASSIGN TO NORTH FLORIDA CHIROPRACTIC CENTER, TO THE EXTENT OF ANY SERVICES RENDERED TO ME BY NORTH FLORIDA CHIROPRACTIC CENTER THE PROCEEDS OF ANY SETTLEMENT OR JUDGEMENT RESULTING FROM THE EXERCISE BY MYSELF OF ANY RIGHTS OF RECOVERY I HAVE AGAINST ANY PERSON OR ORGANIZATION LEGALLY RESPONSIBLE FOR THE BODILY INJURY FOR WHICH I HAVE BEEN RENDERED TREATMENT AND/OR THE PROCEEDS OF MY INSURANCE POLICY UNDER WHICH SUCH SERVICES ARE COVERED AND AGAINST WHICH I MAY MAKE A CLAIM FOR PAYMENT.
I FURTHER AUTHORIZE AND DIRECT YOU MY INSURANCE COMPANY WHICH IS POTENTIALLY LIABLE TO ME UNDER COVERAGE PROVISIONS OF AN INSURANCE POLICY I HOLD WITH YOU. I AGREE THAT NORTH FLORIDA CHIROPRACTIC CENTER BE GIVEN POWER OF ATTORNEY TO ENDORSE/SIGN MY NAME ON ANY AND ALL CHECKS FOR PAYMENTS OF MY DOCTOR'S BILL. I ALSO AUTHORIZE THE RELEASE OF ANY INFORMATION PERTINENT TO MY CASE TO ANY INSURANCE COMPANY ADJUSTER OR ATTORNEY INVOLVED IN THE CASE. A PHOTOCOPY OF THIS AGREEMENT SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS IS THE ORIGINAL.
THIS ASSIGNMENT IS MADE IN CONSIDERATION OF NORTH FLORIDA CHIROPRACTIC CENTER AWAITING PAYMENT FOR SERVICES RENDERED. I UNDERSTAND AND THAT THIS NO WAY RELIEVES ME OF MY PRIMARY OBLIGATION TO PAY FOR SUCH SERVICES THAT THE SIGNING OF THIS FORM DOES NOT PROHIBIT CUSTOMARY BILLING BY YOU. I UNDERSTAND THAT I WILL BE LIABLE FOR ANY BALANCE WHICH REMAINS UNPAID AFTER APPLICATION OF ANY PAYMENT UNDER THIS ASSIGNMENT.
Emergency Contact
INFORMED CONSENT TO MEDICAL AND/OR CHIROPRACTIC TREATMENT AND CARE
- I have been informed that it si not uncommon that patients have some increased discomfort after an adjustment. If that happens I will apply ice to the area and rest it. If I am concerned about this discomfort or develop any new symptoms, I can call the office during regular business hours for emergency attention.If I am out of town or unable to contact the doctor, I can present myself to an emergency room. If any tests were preformed outside of this office (lab or other diagnostic procedures), I understand that the doctor will notify me of the results at my next scheduled appointment.
- I hearby request and consent to the performance of chiropractic and/or medical adjustments, including various modes of physical therapy and if necessary, diagnostic x-rays, on me by Dr. Michael Wood and/or in this clinic authorized by Dr. Michael Wood. I have had an opportunity to discuss with the doctor and/or with other office or clinic personnel, the nature and purpose of chiropractic and/or medicaladjustments and other procedures. I understand that results are not guaranteed.I further understand and am informed that, as in all health care, in the practice of chiropractic and/or medical, there are some very slight risks to treatment, including, but not limited to, muscle strains, disc injuries, and strokes. 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 judgement during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interests.
- I have read the above consent, with the doctor. I have also had an opportunity to ask questions about its content, and by signing I agree to the above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions for which I seek treatment.
Reason for this Visit
Place an X on the image below, where you feel pain, numbness or tingling:
Health Conditions
Please check each of the diseases, conditions, or symptoms that you have now or have had in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan, and the possibility of being accepted for care.
Health Habits
ACCIDENTAL INJURY REPORT-TRAFFIC ACCIDENT
I DO SWEAR THAT THE INJURIES I SUFFER FROM WERE SUSTAINED IN AN AUTOMOBILE ACCIDENT. I AUTHORIZE NORTH FLORIDA CHIROPRACTIC CENTER OR ANY MEMBER OF THE STAFF TO TREAT ME WITH WHATEVER MEAN DEEMED NECESSARY BY THEM FOR MY MAXIMUM RECOVERY. I FURTHER TAKE FULL RESPONSIBILITY FOR ANY REPERCUSSIONS, EITHER CIVIL OR CRIMINAL, SHOULD ANY ACTION ON MY PART OR STATEMENT THAT I HAVE MADE BE DISCOVERED IN THE FUTURE TO BE FALSE OR DECEITFUL.
Experience with Chiropractic
Initial Consultation Form
