Patient Forms

Patient History

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Emergency Contact

Reason for this Visit

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Place an X on the image below, where you feel pain, numbness or tingling:

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Additional Questions

Health Conditions 

Please check each of the diseases or conditions that you have had now or 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.

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FOR WOMEN ONLY:

Privacy and HIPAA

This office conforms to the current HIPAA guidelines. You may request a copy of our HIPAA policy at any time from the front desk, print a copy on our website or find a copy posted in our waiting area. I also understand there is a possibility my conversations may be overheard since there are no doors on the treatment rooms. I may request, prior to my appointment, to have time set aside to discuss matters in a more private manner. I acknowledge that my first name may be announced in the waiting room when my treatment room is available.

Authorization for Care

I hereby request and consent to the performance of chiropractic adjustments and other therapy procedures to be performed on myself by the doctor. I also consent to the procedures performed by his trained staff assistants under direct instruction and supervision.

I have had an opportunity to discuss with the doctor or other office personnel the nature and purpose of chiropractic adjustments and other therapy procedures. I understand that the practice of neither chiropractic nor medicine is an exact science and that my care may involve the making of judgments based upon the facts known to the doctor at the time; that it is not reasonable to expect the doctor to be able to anticipate or explain all risks and complications; that an undesirable result does not necessarily indicate an error in judgment; that no guarantee to results has been made to, nor relied upon by, me, and I wish to rely on the doctor to exercise judgment during the course of the procedures which he feels at the time, based upon the facts then known, is in my best interests.

I have also been advised that although the incidence of complications associated with chiropractic procedures is very low, anyone undergoing chiropractic adjustments, physical therapy services or joint manipulation procedures should know of possible complications, which have been alleged. These include, but are not limited to; burns, fractures, disc injuries, strokes, dislocations, sprains, increase or worsening of symptoms and those which relate to physical aberrations unknown or reasonably undetectable by the doctor.

I have read or have had read to me the above Consent. I have also had the opportunity to ask questions about its' contents, and by signing below, acknowledge my understanding of its contents.

Patient-Doctor Agreement (7 of 7)

The purpose of this agreement is to make sure we are able to best serve you. The scheduled appointments are made for a reason, they attempt to keep patient wait times down and allow for the best patient care possible.

_________ I authorize the release of any records completed and/or obtained by Fisher Chiropractic to my                                 insurance company, attorney, referral physician and/or insurance adjustor.

Cash Pay Patient Financial Policy- All fees are due at the time of service unless previous arrangements have been made with this office. We are happy to accept cash, check, MasterCard, Visa, Discover, and American Express. We do not accept Care Credit.

Medicare Financial Policy- Original Medicare covers 80% of approved services after the deductible is met. Medicare does not pay for evaluations, re-exams, or x-rays. Medicare will not pay for maintenance care, but episodes of care where notable progress is being made.

Major Medical/Group Insurance- Payment is expected at time of visit. Please give all insurance information (secondary policies included) to the Front Desk Coordinator along with a copy of your card(s) and a form of ID. 

Auto Accident/Personal Injury- Fees are usually covered 100% for these injuries; however, YOU are ultimately responsible for any balance on your account. When using PIP, personal injury protection, you are responsible for providing this office with the name of your insurance company and the adjuster's name and contact information. You are also responsible for reporting the accident to your insurance company/agent. You hereby assign benefits payable for the eligible claims to Fisher Chiropractic for submitting your claims to attorney/insurance company and you authorize attorney/insurance company to issue payment directly to Fisher Chiropractic. In the case that you are no longer under contract with your attorney, whatever the cause, or your PIP is exhausted, you understand that you remain responsible for payment to the Provider for any services rendered and/ or supplies provided. You understand that this Assignment will apply to all eligible claims submitted by Fisher Chiropractic. If you are a Parent, Guardian, or Personal Representative, you confirm that you are authorized by the member to execute an assignment of benefit payments to Fisher Chiropractic.

Phone Consent and Authorized Contact

IMPORTANT:

IMPORTANT: If you are using insurance, please bring a copy of your insurance card to your appt along with a form of ID. If you are using PIP, please have your adjuster's contact information and claim number. If you are under contract with an attorney, please have your attorney's contact information. There may also be additional paperwork that will need to be completed at time of arrival. We look forward to meeting you!