328 W Howard St

Live Oak, FL 32064 US

(386) 362-2022

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Auto Injury Online Form

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

Male
Female
Other
Married
Single
Widow

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

      Auto
      Fall
      Other
      Gotten worse
      Stayed Constant
      Comes and goes
      Work
      Sleep
      Daily Routine
      Other activities
      No
      Yes

      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.


      Severe or Frequent Headaches
      Sinus Problems
      Dizziness
      Cancer
      Loss of Sleep
      Hepatitis
      Pain Between the Shoulders
      Frequent Neck Pain
      Numbness or Pain in Arms/Legs/Hands
      Lower Back Problems
      Digestive Problems
      Ulcers/Colitis
      Heart Attack/Stroke
      Thyroid Problems
      Kidney Problems
      Congenital Heart Detect
      Heart Surgery/Pacemaker
      High/Low Blood Pressure
      Psychiatric Problems
      Difficulty Breathing
      Rheumatic Fever
      Asthma
      Arthritis
      Alcohol/Drug Abuse
      Venereal Disease
      HIV/AIDS
      Diabetes
      Tuberculosis
      Shingles
      Chemotherapy
      Anemia
      Muscle Pain
      Fever
      Chills
      Fatigue
      Eye Pain
      Blurred Vision
      Double Vision
      Headaches
      Joint Swelling
      Nosebleed
      Ringing in Ears
      Chest Pain
      Skin Changes
      Fainting
      Wheezing
      Chest Tightness
      Anxiety
      Heartburn
      Nausea
      Vomiting
      Constipation
      Diarrhea
      Bloody Stool
      Joint Stiffness
      Difficult/Painful Urination
      Unexpected weight loss/gain
      Difficulty Swallowing
      Heart Palpitations
      Shortness of Breath
      Poor Wound Healing
      Depression
      Tremors
      Seizures
      Easy Bleeding/Bruising
      Excessive Thirst
      Excessive Urination
      Allergic Reactions

      Health Habits

      Nerve Pills
      Pain Killers (including Aspirins)
      Muscle Relaxers
      Blood Pressure Medicine
      Insulin
      Stimulants
      Blood Thinners
      Tranquilizers
      Daily
      Moderately
      No

      MEDICAL HISTORY

      Broken Bones?
      Been Hospitalized?
      Been in an auto accident?
      Had sprains/strains?
      Been struck unconscious?
      Had surgery?

      INSURANCE INFORMATION

      ACCIDENTAL INJURY REPORT-TRAFFIC ACCIDENT


      IF YOU HAVE AN ATTORNEY



      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 

      Yes
      No

      Initial Consultation Form 


      Constant - 100% of the time
      Frequent - 75%
      Intermittent - 50%
      Occasional - 25%
      Minimal (An annoyance but has no effect on activity)
      Slight (Tolerable with some impairment to activity)
      Moderate (Tolerable with marked impairment of activity)
      Severe (Intolerable and cannot perform any activities)
      0%
      10%
      20%
      30%
      40%
      50%
      60%
      70%
      80%
      90%
      100%

      Thank you for taking the time to fill out this form.

      Sign-up using the form below or call us at (386) 362-2022 to make an appointment

      Office Hours

      Our Regular Schedule

      North Florida Chiropractic Center

      Monday:

      8:30 AM - 12:00 PM

      1:30 PM - 5:30 PM

      Tuesday:

      Closed

      Closed

      Wednesday:

      8:30 AM - 12:00 PM

      1:30 PM - 5:30 PM

      Thursday:

      9:00 AM - 12:00 PM

      1:30 PM - 5:30 PM

      Friday:

      8:30 AM - 12:00 PM

      Closed

      Saturday:

      Closed

      Closed

      Sunday:

      Closed

      Closed

      Location

      Find us on the map

      Testimonial

      • "North Florida Chiropractic has the friendliest staff. They are all extremely caring."
        Taylor B. / Live Oak, FL

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