New Patient Intake Form

New Hanover Chiropractic – Patient Intake Information

General Information

Employer Information

Condition Information

Insured’s Information

Please give receptionist your insurance cards. If insured person is other than patient, please continue BELOW.

Authorization to pay benefits to Physician

I hereby authorize payment from my insurance company directly to the physician of chiropractic benefits, if any, otherwise payable to me for this service as described including Medicare Benefits. I further authorize the release of medical information about me to process medical claims in accordance with the Notice of Privacy furnished to me upon request. THIS IS A DIRECT ASSIGNMENT OF MY

RIGHTS AND BENEFITS UNDER MY INSURANCE POLICY. This payment will not exceed my indebtedness to New Hanover Chiropractic Clinic, and I agree to pay, in a current manner, any balance of professional charges over and above this insurance

payment.

Acknowledgement of Notice of Privacy Practice

The undersigned hereby acknowledges that upon request I may receive a copy of the Notice of Privacy Practices of New Hanover Chiropractic Clinic. By my signature below, I give my permission to use and disclose my health information, for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.

INFORMED CONSENT TO CHIROPRACTIC TREATMENT

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including various modes of physical therapy, and if necessary, diagnostic x-rays on me (or on the patient named below) by the chiropractic physician and/or anyone working in this office authorized by the chiropractic physician.

I further understand that such chiropractic services may be performed by the Physician of Chiropractic named here, Dr. William Genther, and/or other licensed Physicians of Chiropractic who may treat me now or in the future at this office. I have had an opportunity to discuss with Dr. William Genther and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine and all healthcare, the practice ofchiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries,strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate andexplain all risks and complications. Further, I wish to rely on the physician to exercise judgment

during the course of the procedure which the physician feels are in my best interests at the time, based

upon the facts then known.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility.

To be completed by the patient:

To be completed by the patient’s representative, if necessary, (e.g. if the patient is a minor or is physically or mentally incapacitated)