& family wellness...durrum chiropractic and family wellness 1318 s. jefferson ave mount...
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RRUMCHIROPRACTIC
& Family Wellness
1318 S Jefferson. Mt. Pleasant, TX I 903.572.1128 | DurrumChiropractic.com
Welcome to Our Clinic!
Thank you for choosing our clinic for yourchiropractic care. We are committed to providingyou and your family with the highest quality ofchiropractic care available. We will be workingtogether toward helping you reach your health andwellness goals.
If you ever have any questions about yourchiropractic care, please don't hesitate to ask. All ofyour questions, even the ones you never thought ofasking, will most likely be answered during yourReport of Findings with the doctor. We look forwardto a long, healthy relationship with you and yourfamily.
OFFICE FEE SCHEDULE AND FINANCIAL POLICY
Financial Policy: We are committed to providing you the best chiropractic care possible in a caring
environment and have established our financial policies to achieve this goal. You will be expected to pay
for your chiropractic care at the time services are rendered unless other arrangements are made m
advance. Other arrangements include our bi-weekly, monthly & prepay Spinal Corrective Phase Plans.
The details of these plans will be discussed with you & all your questions will be answered at the time of
your Report of Findings (second scheduled visit).
Health insurance Policy: If you have insurance that covers chiropractic, we will give you a copy of the
necessary paperwork upon request so that you may submit a claim to your insurance provider for
reimbursement. It is your responsibility to send this information to your insurance provider. Your
insurance company will communicate with you about your reimbursement. Remember, your agreement
with the insurance company is between you and them, not us and them.
Medicare Policy: An ABN Option 1 is required with a signature before receiving care. Option 1 statesyou will only be reimbursed for 30 adjustments per calendar year from Medicare. After completion of
the 30 adjustments, you will then be required to sign an ABN Option 2 which states you still want to
receive care, but will not bill Medicare.
Service Normal Fees
New Patient visit $275
Adjustments $50
Progress exams $30
X-rays $30 per view
E-Stim $35.00
Ultrasound $10.00
Rehab (intersegmental table & Power Vibe) $30 per session
Fees and pricing structures are subject to a 196-2% increase at any time. You will be given 30 Day notice prior to
changes going into effect.
Payment InformationName of person responsible for payment: (print please).
I understand and agree that I am personally responsible for payment of all fees charged by this office for care. I
also understand that if I suspend or terminate care and treatment, any fees for professional services rendered or
any outstanding balance on equipment/supplements placed upon the account will be immediately due and
payable.
Dated the day of , 20
Signature (person responsible for payment)
Patient Signature (if different than person responsible for payment)
DurrumCHI ROPRACTIC
Name: (MI ) Nick Name: SS#:
Address: City: State: Zip: Age:
Home Phone: Cell Phone: ^Email: Date of Birth / /
Sex: □ M □ F Occupation: Employer: Work Phone:
Marital Status: DMOsnDnw
Next of Kin: Relationship:
Next of Kin Phone Number:
Who May we 'Thank" for referring you to our office?
Would you like to receive text message reminders of future appointment? Yes or No Ph #_
Why this form is important: As a full spectrum Chiropractic office, we focus on your ability to be healthy. Answeringthe following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to betterassess the challenges you may face in regard to reaching your full health potential.
Past Chiropractic Care: Q Yes □ No This Year? Q Yes O No Previous chiropractor:What other wellness professionals are currently part of your healthcare team?^ Massage Therapist QAcupuncturist Q Other
List previous surgeries and dates:
List all Medications (prescription and over the counter^)
I I Pain Meds Q Anti-inflammatories □ Birth Control □ Heart Meds □ Cholesterol Meds □ OtherRepeated/Prolonged Antibiotic use?CII Yes Q No Inhaler Use? dlYes \Z\ NoWere you vaccinated? QYcs □ No Head Trauma? ^Yes Q NoFall/Jump from a height < 3 feet? QYes ONo Youth Sports? lUlYes □ NoFall/Jump from a height > 3 feet? QYes □ No Contact/Extreme Sports? QYes d No(i.e. crib, bunk bed, tree) Drug abuse? QYes Q NoSmoker? dYes d No Auto Accidents? dYes d NoAlcohol Consumption? dYes d NoOn a scale of 1 to 10 describe your stress level: (1 = None, 10= Extreme) Occupational: Personal:
Other Traumas? (Physical or Emotional)dYes d NoAs a child were you under regular Chiropractic Care? dYes d NoOn a scale of: Poor, Good or Excellent describe your:
Diet Exercise Sleep General Health
Rate your daily energy level: dHigh d Normal dLow d No energyAre there any other health concerns that we should be aware of? (MS, Diabetes, Chrons) dYes dNo
DurrumCHIROPRACTIC
Addressing the Issues That Brought You to Our Clinic
If you do not have any symptoms or complaints and are here for wellness care please check here. □Please briefly describe the chief area of complaint, including the effect it has had on your life.
Your Chief Complaint:
If you are experiencing pain, is it:
O Sharp QDuII Q Comes & goes □ Travels O Constant Other Q
When did this begin?
What makes it worse?
What makes it better?
_Since the problem started, is it: □ About the same Q Getting better □ Getting worse
Yes, it interferes with □ Work Q Sleep □ Walking DSitting nStairs nLifting □Hobbies.Other Doctors seen for this problem (Please List)
□ Chiropractor□ Medical Doctor
□ Other
□ Leisure
Health History Please check all the following health concerns that you have experienced, even if you do not think theyrelate to your present health condition
Anxiety □Yes □ No Asthma □Yes □ No
Depression □Yes □No Sinus Troubles □Yes □ No
Mood Swings □Yes □ No Allergies □Yes □ No
Arthritis □Yes □No Skin Conditions □Yes □ No
Osteoporosis □Yes □ No CirculatoryA^ascular Disease □Yes □ NoCancer □Yes □ No Heartburn/Acid Reflux / GERD □Yes □ NoImmune System Disorders □Yes □ No Kidney Disease □Yes □No
Heart Conditions □Yes □No Mid - Back Pain □Yes □NoNeck Pain □Yes □ No Low back Pain □Yes □No
Dizziness □Yes □ No Numbness/Tingling Legs □Yes □ No
Headaches □Yes □ No Diarrhea □Yes □ No
Numbness/Tingling armsor hands
□Yes □No Constipation □Yes □ No
Vertigo / Dizziness □Yes □No Bladder Problems □Yes □NoDifficulty Breathing Deeply □Yes □No Menstrual Cramps □Yes □NoHeart Palpitations □Yes □No Infertility □Yes □ NoDo you sleep well at night? □Yes □ No Are you well rested in the mornings? □Yes □No
CONSENT TO X-RAY
hereby authorize Dr. Durrum and whomever she designates as her assistants to take
X-rays of myself (or said minor). Date Signature.
PREGNANCY WARNING
I understand that if I am pregnant and have X-rays taken which could expose my lower torso to
radiation, it is possible to injure the fetus.
I have been advised that the 10 days following the onset of a menstrual period are generally
considered to be safe for X-ray examination.
With those factors in mind, 1 am advising my doctor that:
1 am pregnant: Yes No Don't Know
1 could be pregnant: Yes No Don't Know
1 have an lUD: Yes No Don't Know
1 have had a tubal llgation: Yes No Don't Know
1 am late with my menstrual period: Yes No Don't Know
1 am taking oral contraceptives: Yes No Don't Know
1 have had a hysterectomy: Yes No Don't Know
1 have irregular menstrual periods: Yes No Don't Know
My last menstrual period began on:
Patient Print Name: Patient's Signature:
Signature of Parent or Guardian (if patient is a minor)
CA Signature:
TERMS OF ACCEPTANCE
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be
working towards the same objective.
The main goal of chiropractic is to correct vertebral subluxations of the spine. It is important that each patient
understand both this objective and the method we will use to attain it. This will prevent any confusion or
disappointment.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the
course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you
do desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health
care provider who specializes in that area.
Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment
prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the
body's innate God-given ability to care for itself. Our only method is specific adjusting of the spine to correct vertebral
subluxations.l therefore accept chiropractic care on this basis.
(Signature) (Date)
DURRUM CHIROPRACTIC AND FAMILY WELLNESS
1318 S. Jefferson Ave
Mount Pleasant, Texas 75455
903-572-1128
Consent to use PHI
Acknowledgement for Consent to Use and Disclosure of Protected Health information
Your Protected Health Information will be used by Durrum Chiropractic and Family Wellness or
may be disclosed to others for the purposes of treatment, obtaining payment, or supporting theday-to-day health care operations of this office.
Notice of Privacy Practices
You should review the Notice of Patient Privacy Practices for a more complete description ofhow your Protected Health Information may be used or disclosed. It describes your rights as
they concern the limited use of health information, including your demographic information,collected from you and created or received by this office. I have received a copy of the Noticeof Patient Privacy Policy. Patient initials
Requesting a Restriction on the Use or Disclosure of Your Information
• You may request a restriction on the use or disclosure of your Protected HealthInformation.
• This office may or may not agree to restrict the use or disclosure of your Protected Health
Information.
• If we agree to your request, the restriction will be binding with this office. Use or
disclosure of protected information in violation of an agreed upon restriction will be a
violation of the federal privacy standards.
Revocation of Consent
You may revoke the consent to the use and disclosure of your Protected Health Information.
You must revoke this consent in writing. Any use or disclosure that has already occurred prior
to the date on which your revocation of consent is received will not be affected.
By my signature below I give my permission to use and disclose my health information.
Patient or Legally Authorized Individual Signature
Print Patient's Full Name
Witness Signature
DURRUM CHIROPRACTIC & FAMILY WELLNESS
Patient Authorization
Regarding "Open Adjusting" Environment
It Is the practice of this office to provide chiropractic care in an "open adjusting" environment. "Open
adjusting" involves 2 patients being seen in the same adjusting room at the same time. Patients are within
sight of one another and some ongoing routine details of care are discussed within earshot of other patients
and staff. This environment is used for ongoing care and is NOT the environment used for taking patient
histories, performing examinations or presenting reported findings. These procedures are completed in a
private, confidential setting. Patient may request and schedule a private consultation at anytime.
Your signature indicates your authorization of this activity.
Name (printed) Date
Authorization To Use Personal Health Information
I authorize Durrum Chiropractic to use any information needed, such as videos or written testimonials, for advertising
purposes on the following:
o YouTube
o Facebook
o Website
o E-mail
o All types of Health Talk Classes
(Print Name) (Signature)
(Date)