New Patient Registration

Complete the patient intake form prior to your visit with Anodyne. We offer two ways for you to complete the form. Download the PDF, print it off and fill it out, and bring it with you. OR, you can also fill the form out online. Please allow about 15 minutes to complete the whole form.

Step 1 of 6

Today's Date

Patient Name *

First

Middle

Last

Date of Birth

Gender Identity

Patient's Current Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

DL #

Marital / Partnership Status

Patient Phone *

If registering a child, please provide the parent or guardian's phone number.

Patient Email Address *

Confirm Email

If registering a child, please provide the parent or guardian's email address.

Employer

Occupation

Emergency Contact Name

Emergency Contact Phone

Are you seeking care due to an auto accident or other injury?

I agree that I am financially responsible for and will pay all incurred charges for all services provided by the Practice and its employees, contractors and providers. The Practice maintains a standard fee schedule, subject to change from time to time. All services shall be paid pursuant to the Practice's then current fee schedule in accordance with the Practice's then-current payment policies, which currently require payment within 30 days of an invoice statement date. I agree to present current insurance information at each visit to the Practice. I understand and agree that if I have health and/or accident insurance policies, that these policies are an arrangement between my insurance company and/or government program and myself. I understand that my insurance benefits may cover part, or none of the services rendered by the Practice. It is my responsibility to understand my insurance benefits including, without limitation, my copays, coverage and deductibles, and any required referrals should I seek to obtain reimbursement from third party payors myself. Any deductibles or copays owed to the Practice pursuant to my insurance policy will not be waived. I understand that it is my responsibility to notify the Practice of any and all changes to my insurance company, plan and/or benefits. I understand that if no insurance coverage exists for any services or products that I receive from the Practice or my insurance carrier(s) fails to pay the Practice, I am financially responsible for the incurred charges and I agree that the above paragraph does not release me from such responsibility. I clearly understand that I am financially responsible for all charges whether or not paid by my insurance carrier or third-party payor. I further agree that I will pay all such incurred charges in accordance with the Practice's then-current payment policies and procedures. I understand that the Practice has the right to forward unpaid accounts to a collections agency and I agree to bear and reimburse the Practice for all costs associated with the Practice's collection efforts on my account.

Late cancellations of less than 2 hours, and patients who do not show for a scheduled appointment will be charged $25.00.

If the services provided are payable under a Medicare or other applicable government or commercially provided benefit, I hereby authorize my payor and/or insurance company to pay the Practice directly for any care I receive from the Practice. I hereby assign all payments and medical benefits directly to the Practice for services rendered by the Practice that would otherwise be payable to me. I understand that any such assignment of benefits imposes no obligation for the Practice to collect money on my behalf.

I hereby agree that the services that I receive from the Practice will consist of the provision of pain and wellness treatments and related items and services.

I hereby agree that the Practice will not be liable for any failure to provide, or delay in providing, services to me in the event that the Practice and its providers are assisting other patient(s) in an emergency or in the event of other circumstances beyond the reasonable control of the Practice. In the event of an Emergency, or a situation in which I could reasonably expect an emergency to arise, I agree to call 911 or visit the nearest emergency room and follow the directions of the emergency personnel.

This serves as notice that as part of our efforts to deliver the most consistent healthcare we can to every patient, we use an electronic healthcare system that enables us to retrieve up to 13 months of prescription history through your insurance carrier.

My signature below evidences my voluntary agreement to receive services from the Practice, and that I am the patient or am authorized to act on behalf of the patient to sign this form. By signing below, I agree that I have read, understand, and agree to all of the statements contained in this document. My signature below further evidences that I have been informed about the services and the purpose, procedures, possible benefits and risks, and that I have been given an opportunity to ask questions before I sign and have been told that I can ask other questions at any time. I understand that my agreement is effective on the date signed below and that I may revoke my agreement to receive services from the Practice in writing, but I may not revoke my agreement to abide by any financial terms set forth herein. My revocation will not be effective for actions already taken by the Practice or that are in progress and will only be prospectively effective.

Patient Name *

First

Last

Signature of Patient, Parent or Legal Guardian

I understand and agree that chiropractic care, like all forms of health care, while offering considerable benefit may also provide some level of risk. This level of risk is most often very minimal. The types of complications that have been reported secondary to chiropractic care include sprain/strain injuries, irritation of a disc condition, and rarely, fractures, one of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be a vertebral artery injury that could lead to stroke.

Prior to receiving chiropractic care, a health history and physical examination will be completed. These procedures are performed to assess my specific condition and my overall health to determine if chiropractic care is an appropriate form of treatment for my condition. All relevant findings will be reported to me along with a care plan prior to beginning care. I understand and accept that there are risks associated with chiropractic care and give consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment.

I have read and understand the above.

Signature

I acknowledge that it is the policy of the Practice and its staff to leave a telephone message regarding my medical care with the following options: (Initial each one that you want us to be able to use for leaving you a telephone message). This will remain in effect until you rescind it in writing.

"I authorize the Practice to send text message and/or email appointment reminders. I understand that text message charges may apply. Email and text messages are not recognized as secure communication forms and your agreement to communicate via text or unencrypted emails on a non-confidential basis at your risk. Please do not send any information you consider private to us by email or text. The Practice is not responsible for the security of any information transmitted using any phone number or email address you provide. If you consent to receive texts or emails from the Practice or any of its employees or contractors, you acknowledge that you are aware of the above-mentioned risks of using text and/or email communications from the Practice and its employees and contractors.

Cell Phone

Signature of Patient, Parent of Legal Guardian

Health Insurance Information

Current Ailment

Health History

Social History