Leif Erik Nielson, DC
Certified Chiropractic Extremity Practitioner (CCEP)
Phone: 435-654-5008 Fax: 435-654-5328
Name: ______________________________________________ Date: _______________________________
Date of Birth: ___/____/_____ Phone: ___________________ Email: _____________________________
Mailing address: __________________________________________________________________________
Occupation______________________ Emergency contact name/# ______________________________
Status: Married___ Single___ Divorced___ Widowed___ Other___ Children: Yes____ No____ #_____
REQUIRED (in bold)
What pain or symptoms? _________________________________________________________________
Which is bothering you the most? ________________________________________________________
Frequency of symptoms (% of each day)?__________________________________________________
When did it start? ( MOST RECENT FLARE-UP)_____________________________________________
How did it start? (fall, accident, lifting, unknown, etc.) _____________________________________
How is this disrupting your life
(daily activities limited or intolerance to sitting, standing, walking, sleeping, chores, etc.)
Please explain: ___________________________________________________________________________ ___________________________________________________________________________________________
Accident History: Is visit because of an accident: ____Yes ____No If yes: ____car ____work
List all Medications: List all Supplements/Herbs:
Any major recent changes (pregnancy, job, divorce, death, exercise, weight loss, miscarriage,etc.) :__________________________________________________________________________________
Significant medical history recent or past; (surgeries, diseases, accidents, fractures, cancer, infections, rheumatoid arthritis, etc):_______________________________________________________________________________
Mark any that apply to you::
__Avoid drinking water
__No regular exercise
__Sit more than 8 hours a day
__Frequent use of drugs and/or alcohol
__Use laptop regularly
__Rarely more than 6 hours sleep
__Multiple food sensitivities
__On special diet
__Live on processed and/or fast food
What are you hoping to get out of your visit today? __________________________________________
How did you find us? (referral, internet, sign, phone book, etc.) ________________________________
CONSENT TO TREATMENT
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy, diagnostic x-rays and therapeutic nutrition on me
(or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up doctor for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.
The nature of the chiropractic adjustment.
The primary treatment I use as a Doctor of Chiropractic is the spinal adjustment. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you experienced when you “crack” your knuckles. You may feel a sense of movement.
I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some
risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. The risk of injuries or complications from treatment is substantially lower than that associated with many medical or other treatments, medications, and procedures given for the same symptoms. Some patients will feel some stiffness and soreness following the first few days of treatment. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, and is in my best interest.
I understand that any nutritional supplements or diet advice that I receive in this clinic is meant to support good health and not to cure any diseases.
The availability and nature of other treatment options.
Other treatment options for your condition may include:
Self-administered, over-the-counter analgesics and rest
Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.
The risks and dangers attendant to remaining untreated.
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I understand that results are not guaranteed. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Patient Signature ________________________________ Doctor’s Name Leif Erik Nielson, DC
Signature of Patient or Parent or Guardian (if a minor)___________________________________
OUR PRIVACY PLEDGE
We are very concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will respect the privacy of your health information.
There are several circumstances in which we may have to use or disclose your health care information:
We may have to disclose your health information to another health care provider or hospital if it is necessary to refer you to them for the diagnosis, assessment, or treatment of your health condition.
We may have to disclose your health information and billing records to another party if they are potentially responsible for the payment of your services.
We may need to use your health care information within our practice for quality control or other operational procedures.
We have a more complete notice that provides a detailed description of how your health information may be used or disclosed. You have the right to review that notice before you sign this consent form (164.520). We reserve the right to change our privacy practices as described in that notice. If we make a change to our privacy practices, we will notify you in writing when you come in for treatment, or by mail. Please feel free to call us at any time for a copy of our privacy notices.
Your Right to Limit Disclosure of Use
You have the right to request that we do not disclose your health information to specific individuals, companies, or organizations. If you would like to place any restrictions on the use or disclosure of your health information, please let us know in writing. We are not required to agree to your restrictions. However, if we agree with your restrictions, they are binding on us.
Your Right to Revoke Your Authorization
You may revoke your consent to us at any time; however, your revocation must be in writing. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. If you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
I have read your consent policy and agree to its terms. I also agree to allow this clinic to contact me by mail, telephone, or any other method for appointment reminders, financial statements, insurance concerns, office promotions, marketing information, fund raising request or any other information that may be of interest to me. I also acknowledge that I have received a copy of this notice, if I desire.
Print Name_____________________________________ Date_______________________________
Signature_____________________________________ Witness Signature______________________________