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Elevated Health Center Auto-Injury Intake
PERSONAL INFORMATION
First Name
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Middle Initial
Last Name
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Birth Date
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Age
Sex:
Male
Female
Address:
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City
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Zip Code:
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State
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Cell Phone Number:
Emergency Contact:
Emergency Contact Phone Number
Auto Insurance? Please provide front and back images of your auto insurance AND a photo ID for verification purposes.
REASON FOR SEEKING CARE
What is your reason for seeking care at Elevated Health Center?
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Date of Accident
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Are there any major injuries and/or surgeries we should know about?
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What is this affecting that is MOST important in your life? (List all that apply)
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ACCIDENT DETAILS
Make/Model/Year of vehicle you were occupying
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Your vehicle was _____________________ upon impact.
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Proceeding along
Stopped
Stopped at intersection
Making a right turn
Stopped in traffic
Making a left turn
Slowing down
Stopped at light
Parking
Stopped at stop sign and accelerating
What part of your vehicle did the other car hit?
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What were the Make/Model/Year of vehicle that made contact with your vehicle? (If applicable)
Visibility at the time of collision was:
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Poor
Fair
Good
What were the road conditions at the time of impact?
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Icy
Wet
Clean
Dry
Did you see the collision coming?
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Yes
No
Were you braced for impact?
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Yes
No
Were you wearing your seat belt?
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Yes. Seat belt with shoulder harness
Yes. Seat belt without shoulder harness
No.
How was the top of your headrest positioned?
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Even with top of my head
Even with the bottom of my head
Even with the middle of my neck, and even with upper back.
What was your hand position during the collision?
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My left hand was on the steering wheel.
My right hand was on the steering wheel.
Both of my hands were on the steering wheel.
I wasn't driving.
Direction of head at time of impact:
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Extended upward
Flexed downward
Turned to the left
Turned to the right
Facing straight forward
Loss of consciousness?
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Yes
No
Airbags deploy?
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Yes
No
Seat break?
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Yes
No
Objects thrown around inside your vehicle? If yes, please indicate (i.e. books, glasses, cell phone)
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No
Yes
Yes
Police arrive at the scene?
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Yes
No
Anyone receive a ticket?
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Yes
No
EMT's arrive at scene?
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Yes
No
Were you taken by ambulance?
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Yes
No
How did your vehicle leave the scene?
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Towed away from the scene
Driven away from the scene
AUTO INSURANCE INFORMATION
Name of Insured/Policy Holder:
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Date of Birth of Policy Holder
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Name of Auto Insurance Company:
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Address of Auto Insurance Company
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Phone Number of Auto Insurance Company
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Claim Number
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Claim Adjuster's Name & Phone Number
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PATIENT HIPAA CONSENT FORM
Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to define situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment, or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view charges to your records. In the future, we may contact you for appointment reminders, announcements, and to inform you about our practice and its staff. I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: conduct, plan, and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly, obtain payment from third party payers, and conduct normal healthcare operations such as quality assessments and physician's certificates. I have read and understand your Notice of Privacy Practices. I also understand that I can request in writing that you restrict how my personal information is used and disclosed.
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Client Name:
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Date:
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PERSONAL INJURY FINANCIAL AGREEMENT
If you were involved in an auto accident in your own vehicle, we will bill the Personal Injury Protection portion to your insurance policy to cover the treatment charges incurred in our office.
Attorney Liens
: If you hire an attorney to represent you in a lawsuit for coverage in a Personal Injury claim, it is our policy to have your attorney sign a Doctor's Lien. This will guarantee direct payment to our office for any unpaid balance upon the settlement of your lawsuit. We retain the right to first submit all charges to your private and/or auto insurance policy for payment. Further,
this office does not discount or reduce the amount of your balance based upon the outcome of your settlement
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Responsibility for Payment
: As a courtesy to you, we will gladly submit your charges to your insurance company(ies) and/or your attorney; however, all services rendered by this office are charged directly to you, and ultimately,
you are personally responsible for payment of these charges, regardless of any insurance reimbursement or settlement you may or may not receive
. If, at any time, you have further questions about your care, please do not hesitate to ask. I have read and agree to the above.
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Client Name
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Date:
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AUTHORIZATION FOR CARE
At Elevated Health Center, we do not diagnose or treat any disease or condition other than vertebral subluxation and the doctors/clinic will not be held responsible for any pre-existing medical conditions. I certify that the above information is correct to the best of my knowledge. I will not hold the doctors or any staff member of Elevated Health Center responsible for any errors or omissions that I may have made in the completion of this form. Chiropractic, as well as all other types of health care is associated with potential risks in the delivery of treatment. While chiropractic treatment is remarkably safe, you need to be informed about the potential risks related to your care to allow you to be fully informed before consenting to treatment. Please inquire if you have further questions. Chiropractic is a system of health care delivery and therefore, as with any health care delivery system, we cannot promise a cure for any symptom, condition, or disease as a result of treatment in this office. An attempt to provide you with the very best care is our goal, and if the results are not acceptable, we will refer you to another provider who we feel can further assist you. I hereby authorize the doctors and staff at Elevated Health Center to treat my condition as deemed appropriate.
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Client Name
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Date:
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CANCELLATION POLICY
Here at EHC, we have a strict 24-hour notice cancellation policy. You may cancel your appointment anytime 24 hours or more before the appointment without a charge. Unless it is an emergency, if a client does not show up OR call to cancel a scheduled appointment, the client will be charged $50.00 for the scheduled visit. Any cancellations or rearrangements within 24 hours preceding said appointment will be charged at $25.00 for the scheduled visit. We understand sometimes life can throw us unexpected emergencies and these unanticipated things are not always within our control. Thank you for your understanding and we look forward to helping you elevate your health! I have read the above statement and agree to the above terms.
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Client Name
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Date:
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