Fairfax Station Chiropractic

New Patient Intake Form

Please complete all sections thoroughly and accurately

All information will be kept strictly confidential

How were you referred to us?^*

Date:^*

Last Name^*

First Name^*

Name you would like to be called^*

Address:^*

Sex:^*

Date of Birth:^*

Age:

SSN:^*

Format: XXX-XX-XXXX

Email:^*

Cell#:^*

Home#:

Work#:

Employer:^*

Employer Address:

Emergency Contact

Name:^*

Relationship:^*

Cell#:^*

Home#:

Work#:

Insurance Information

Name of Insurance Company:^*

Name of Insured:^*

Relationship to Patient:^*

Insurance Coverage Company Name^*

Assignment text 1

I. I, the undersigned certify that I (or my dependent) have insurance coverage with the company named above and assign directly to Dr. Christopher C. Virusky and Fairfax Station Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered.

Assignment text 2

II. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance claims.

Assignment text 3

III. I understand and agree that I will be financially responsible for any and all actual collection costs that are incurred which could be as much as 50% of the unpaid balance should my account become delinquent and is referred to a collection agency or attorney.

Assignment text 4

IV. I understand and agree that any delinquent account will accrue interest at 1.5% per month or 18% per annum.

Signature of Insured^*

Patient Signature^*

Select body parts that are in pain

Neck Disability Index

Please rate your current level of neck function

Pain Intensity^*

Current: 0

No pain

Sleeping^*

Current: 0

No trouble sleeping

Reading^*

Current: 0

I can read as much as I want with no neck pain

Concentration^*

Current: 0

I can concentrate fully when I want with no difficulty

Work^*

Current: 0

I can do as much work as I want

Back Disability Index

Please rate your current level of back function

Pain Intensity^*

Current: 0

The pain comes and goes and is very mild

Sleeping^*

Current: 0

I get no pain in bed

Sitting^*

Current: 0

I can sit in any chair as long as I like

Acknowledgment of Receipt of Notice of Privacy Practices Financial Policy and Informed Consent

Privacy notice 1

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

Privacy rights

The right to review the notice prior to signing this consent.
The right to object to the use of my health information for directory purposes.
The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment or health care operations.

Patient signature^*

Date

Name(Print)^*

By submitting this form, you acknowledge that all information provided is accurate and complete.

For questions about this form, please contact our office.