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(732) 833-9000

Intrinsic Chiropractic Center offers our patient forms online so they can be completed it in the convenience of your own home or office.

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  • Fax us your printed and completed form(s) or bring it with you to your appointment.

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/NP_Form_Pg_1.pub

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/NP_Form_pg2.pub

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/HIPPAform.doc

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/EHRintake.doc

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/consenttreatxray.doc

https://intrinsicchirocom.chiromatrixbase.com/clients/5926/documents/assignmentfinancial.doc



Name: _________________________Home Phone:_________________

Cell Phone:____________
Address: _____________________________ ____

City/State/Zip:___________________________
D.O.B.___________ _Age:_______Who may me thank for referring You?____________________
Is this for the whole family? Family: ______ Self: ________ Medicare Yes/No Car Accident  Yes/No
Primary reason for consulting our office:________________________________________________
Occupation: _________________________________ Employer: ____________________________
Sex: M / F Single / Married / Divorced / Widowed    Spouse's Name: _________________________
Name and Ages of Children: __________________________________________________________
Email: ______________________________________ Social Security Number: ________________
Your hobbies/interests/activities: ______________________________________________________
Do you exercise? NO / YES How often?_______________ What type: ________________________
Rate your diet: Healthy   Average  Poor   Do you use supplements YES  NO ____________________
Alcohol:  Never / Rare / Moderate / Daily 
Smoker? NO / YES ____ # Packs/day since year: ___ Past Smoker? NO / YES  

What is the reason for consulting our office ?
___  Symptom Relief ___  Maintaining Your Current Level of Health   ___ Optimum Wellness

Previous chiropractic care?  YES / NO  If yes, Dr.'s Name _____________________ Last Visit ____
Other doctors you are currently seeing: _________________________________________________
Current medications: ________________________________________________________________
Over the counter drugs taken in the past 3 months: ________________________________________
List all surgeries: ___________________________________________________________________
_________________________________________________________________________________
List all accidents and falls: ___________________________________________________________
_________________________________________________________________________________

Health is the most valuable asset in the world for you and your family.  Healing includes taking responsibility for that health.  Aspects of this responsibility are attending health workshops, following your care plan and meeting your financial obligations.  Chiropractic is not a treatment nor a cure for any disease.  The goal of chiropractic care is for restoration and maintenance of full function and communication within the body, from the brain to every cell in the body so that you may express full potential for life and healing. 



Intrinsic Chiropractic Center, Dr. Jodi Kinney, 100 W. Veterans Hwy. Jackson, NJ 08527 (732)833-9000
Page 1    

Patient's Name____________________________________________________Date______/______/______


***If you are NOT experiencing ANY symptoms, please go to Section B: Health History***

Section A: Current Problem Please answer the following questions regarding your current problem:

Please mark on the picture, where you have any problems.
Date of Onset: ___________    Cause of Condition (if known)_____________________
How often during the day do you experience this?    
___ 0-25%    ___ 25-50%     ___ 50-75%    ___ 75-100%

Describe the pain: ___ sharp  ___ dull ___ achy   ___  stiff   ___ shooting  ___ burning   ___ spasm
How severe is this problem?  No Pain   1    2    3    4    5    6    7    8    9    10    Extreme
Since the onset, is the pain?  ___ worse   ___ better   ___ same   ___on & off
Is there anything that makes it worse? ___ standing  ___ sitting   ___ lying down  ___ motion
Is there anything that makes it better?  ___ standing  ___ sitting   ___ lying down  ___ motion
Is this problem?  ___ Better or ___ Worse   ___ AM or  ___ PM    ___ Neither
Are any systems involved? ___ Digestive  ___ Cardiovascular   ___ Respiratory   ___ Elimination   ___ Reproductive    
Does the pain cause you to? ___ Lose sleep   ___ Be short tempered   ___ Miss work   ___ Miss play   ___ Lose focus
What has this problem kept you from enjoying? ___________________________________________________     
Have you had a similar condition in the past?  Y  N  If yes, explain: ___________________________________
What treatment(s) have you already had for this problem?
    Medication    Surgery     Physical Therapy     Chiropractic     None    Other:__________________
What was the outcome of this treatment?_______________________________________________________________
Any other facts about your current problem or pain: ____________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________
Is there any chance you could be pregnant?  YES  NO  Date of last menstrual period:_____________________________

Section B: Health History (Please check if you have had or are currently experiencing any of the following:)
 Anxiety      Anemia      Arthritis          Thyroid Problems          Bowel Problems
 Cancer     HIV/AIDS      Tuberculosis          High Blood Pressure          Heart Trouble
 Diabetes      Hepatitis      Insomnia         Venereal Disease          Muscular Dystrophy
 Epilepsy      Dizziness      Convulsions          Multiple Sclerosis          Rheumatic Fever
 Neuritis      Asthma      Scarlet Fever      Digestive Problems          Sinus Trouble
 Allergies      Backaches      Numbness          Frequent Colds          Nervousness    
 Stroke      Depression     Headaches         Cold Hands/Feet         Restless Sleep
 Ulcer      Irritability     Impulsivity         Low Pain Threshold         Fibromyalgia
 Hernia     PMS         Bruising         German Measles         Osteoporosis
 Nausea     Swelling     Mood Swings     Chronic Fatigue Syndrome     Infertility
Describe other details about YOUR Past Medical History:__________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section C: Family History (Your Blood Relatives Only)
‡ Diabetes      Heart Disease   Cancer    Thyroid Problems    Stroke    Multiple Sclerosis
‡ Other: _________________________________________________________________________________________



Patient/Guardian Signature: _______________________________________Date:_______________________________

Intrinsic Chiropractic Center
Confidential New Member Information

Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.

________________________________________________________________________
                                      100 W. Veterans Highway
                                                              Suite 7
                                    Jackson, NJ 08527
                                          (732) 833-9000


Consent to Professional Treatment
The patient certifies that all information provided to this office is true and correct, to the best of their knowledge. The patient grants their consent to this office and its staff to render treatment as deemed necessary by the attending physician. If the patient is a minor child, under the age of eighteen (18) at the date of treatment, I hereby stipulate that I am the legal guardian of the child, and grant my consent for the treatment of the child as provided for herein. The patient may refuse treatment at any time.
_________________________________            _______________
Signature                            Date


Consent to Perform and Interpret X-rays
The patient consents to the performance of x-rays as deemed necessary by the attending physician of this office. The patient acknowledges that certain risks are associated with x-rays. The patient, hereby states that they have no known limitations that would forbid the taking of x-rays.
The patient further agrees that this office may seek outside interpretation of patient x-rays by a qualified professional not employed by this office. The patient agrees to any additional fees associated with this service and assigns benefits to be paid directly to that professional by your third-party payor.



_________________________________            _______________
Signature                            Date

Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.
________________________________________________________________________
                                      100 W. Veterans Highway
                                                              Suite 7
                                    Jackson, NJ 08527
                                          (732) 833-9000



Assignment of Benefits and Release of Records
The patient hereby assigns benefits to be paid directly to this provider by all of their third party payors. This assignment is irrevocable. Failure to fulfill this obligation will be considered a breach of contract between the patient and this office.
The patient authorizes this office to release any information required by a third party payor necessary for reimbursement of charges incurred.
_________________________________            _______________
Signature                            Date

Financial Obligation and Appointment Policy
The patient accepts full financial responsibility for services rendered by this practice. Payment in full is required for all services rendered at the time of visit, unless alternative arrangements have been agreed to in advance. Patient accepts full responsibility for any fees incurred, including but not limited to legal fees, collection agency fees, and any and all other expenses incurred in the collection of past due accounts. Patient should direct any questions regarding this financial obligation and appointment policy to the clinic manager or physician.
The patient further authorizes the practice to retain credit card, debit card, checking account or other payment source(s) supplied by patient to the practice for current and future charges, when incurred.


_________________________________            _______________
Signature                            Date

Intrinsic Chiropractic Center
Jodi L. Kinney, D.C.
________________________________________________________________________
                                      100 W. Veterans Highway
                                                              Suite 7
                                    Jackson, NJ 08527
                                          (732) 833-9000
Patient Health Information and
Privacy Policy
This policy outlines the way Patient Health Information (PHI) will be used in this office and the patient's rights concerning those records. You must read and consent to this policy before receiving services. A complete copy of the Health Information Portability and Accountability Act (HIPAA) is available here: Final Rule as seen in Federal Register 2/20/2003
1.    The patient understands and agrees to allow this office to use their PHI for the purpose of treatment, payment, health care operations and coordination of care. The patient agrees to allow this office to submit requested PHI to the payor(s) named by the patient for the purpose of payment. This office will limit the release of all PHI to the minimum necessary to receive payment.
2.    The patient has the right to examine and obtain a copy of their health records at any time and request corrections. The patient may request to know what disclosures have been made, and submit in writing any further restrictions on the use of their PHI. This office is not obligated to agree to those restrictions.
3.    The patient's written consent shall remain in effect for as long as the patient receives care at this office, regardless of the passage of time, unless the patient provides written notice to revoke their consent. A revocation of consent will not apply to any prior care or services.
4.    This office is committed to protecting your PHI and meeting its HIPAA obligations: Staff have been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures.
5.    Patients have the right to file a formal complaint with our privacy official about any suspected violations.
6.    This office has the right to refuse treatment if the patient does not accept the terms of this policy.

_________________________________            _______________
Signature                            Date


                                                                                                         Dr. Jodi Kinney                                  100 W. Veterans Highway

                                                                                                                                                              Suite 7

                                                                                                                                                Jackson, NJ 08527

                                                                                                                                   Phone- (732) 833-9000

Fax-(732)833-9932

Electronic Health Records Intake Form

In compliance with Medicare requirements for the government EHR incentive program

 

First Name:_________________________

Last Name:_________________________

Email address:  _________________@_________________

Preferred method of communication for patient reminders (Circle one):  Email / Phone / Mail

DOB:   __/__/____     Gender (Circle one):   Male / Female Preferred Language:  __________________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked

 

CMS requires providers to report both race and ethnicity

Race (Circle one):   American Indian or Alaska Native / Asian / Black or African American / White (Caucasian)  Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one):  Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name

Dosage and Frequency (i.e. 5mg once a day, etc.)

 

 

 

 

 

 

Do you have any medication allergies?

Medication Name

Reaction

Onset Date

Additional  Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.)

Patient Signature: _____________________________________________   Date:________________

For office use only

Height: _________       Weight:____________    Blood Pressure:______ /______

 


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