WELCOME
We’d like to welcome you as a new patient. Please take the time to fill out this form as accurately as possible
so we can most appropriately address your health needs. The confidentiality of your health information is
protected in accordance with federal protections for the privacy of health information under the Health
Insurance Portability and Accountability Act (HIPAA).
Today’s Date:
/
/_____
Patient Name: _______________________________________________________________________
LAST
FIRST
Address: _______________________________________________
State: ___________________
DOB: _____________________
Zip Code: ______________
Age: ____________
MI
City:_____________________
SS#____________________________
Sex (please circle)
M
or
F
Employer: _____________________________________Occupation: ____________________________
Phone (Cell): ___________________________________ Home: _______________________________
Status: ( ) Minor
( ) Single
( ) Married
( ) Divorced
( ) Separated ( ) Widowed
Number of Children: _________
Email: ____________________________@ ________________.com
IN CASE OF EMERGENCY, CONTACT:
Name: ______________________________________
Relationship: ___________________________
Home Phone: _________________________________ Cell: __________________________________
INSURANCE INFORMATION:
Company Name: ________________________________________ Tel #: _________________________
Insured’s Name: ___________________________________ DOB: ____________________
Policy #: __________________________________ Group #: _________________________________
Please present insurance card(s) and picture identification so we can put a copy in your file
Pain Chart
About you
Name: ______________________________________________________
Height__________
Weight____________ Lbs
Please describe your condition: ______________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________.
Signature: _________________________________________________________________
SHOW US WHERE IT HURTS
Date:_____/_____/_____
Reason for today’s visit:
( ) Emergency
( ) New Injury
( ) Old Injury
( ) Chronic Pain
( ) Wellness
What is your major symptom/problem?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________.
Are you in Pain?
( ) Yes
( ) No
Is your condition getting progressively worse?
( ) Yes
( ) No
Is this problem:
( ) constant ( ) comes and goes
How does it feel? ( ) Burning ( ) Sharp
( ) Shooting ( ) Dull
( ) Aching
( ) Stiff
( ) Tingling
( ) Throbbing ( ) Swelling ( ) other (Please explain)________________________________.
What makes your condition better? _________________________________________________________________________.
What makes your condition worse? ________________________________________________________________________.
Does it interfere with your:
( ) Work
( ) Sleep ( ) Daily Routine
( ) Recreation
If so, how ______________________________________________________________________________________________________.
Activities/movements that are painful to perform:
( ) Sitting
( ) Standing ( ) Walking
( ) Bending
( ) Lying down
( ) Driving
( ) Reading
( ) Getting Up
What other treatments have you had for this condition?
( ) Chiropractic ( ) Orthopedic ( ) Neurologist ( ) Physical Therapy ( ) Medication ( ) Surgery
Name of other doctors who have treated you for this condition: _________________________________________
__________________________________________________________________________________________________________________.
Describe the other doctor’s treatment for your condition: ________________________________________________
__________________________________________________________________________________________________________________.
Previous chiropractic care? ( ) No ( ) Yes
Date:
/
/_____
Date of Last:
Physical Exam_____________________
Spinal X-ray__________________
MRI ________________
CT Scan _______________
Spinal Exam ___________________
Dental x-ray_________________
List any Medications you are taking__________________________________________________________________________
__________________________________________________________________________________________________________________.
Vitamins / Herbs / Minerals _________________________________________________________________________________.
Females: Are you Pregnant ( ) Yes ( ) No:
Please Initial: __________________.
If yes, how many weeks:______________________ Beginning of last menstrual cycle: ___________________
Are you taking any of the following medications?
( ) Nerve pills
( ) Pain Killers (including aspirin)
( ) Muscle relaxers
Check any of the following conditions you have or have had:
__AIDS/HIV
__Ear ringing
__ Allergies
__ Epilepsy
__Anxiety/Depression
__Headaches
__Arm/shoulder pain
__Headaches
__Arthritis
__Heart Disease
__Asthma
__Heart Murmur
__Anemia/Diabetes
__Hemorrhoids
__Bladder problems
__Herniated disk
__Cancer
__Hepatitis
__Chronic fatigue
__High blood pressure
__ Deafness
__ Insomnia
__ Diabetes
__Irregular cycle
__ Digestion problems
__ Kidney problems
__Earache
__ Leg pain
STRESSORS EXERCISE
( ) Smoking
( ) Alcohol
( ) Coffee/ Caffeine
( ) High Stress Level
Packs/Day ________
Drinks/Week ______
Drinks Cups/Day _________
Reason _________________________________________
Have you had any: Description
Automobile accidents: ________________________________________________________________
Surgeries: ______________________________________________________________________________
Broken bones: _________________________________________________________________________
Falls/Head injuries: ___________________________________________________________________
__ Low back pain
__Migraine
__Neck pain
__Osteoporosis
__Poor circulation
__Prostate problems
__Rheumatoid/Arthritis
__Sciatica
__Shingles
__Sinus infection
__Stroke
__Thyroid problem
__TMJ
__Venereal disease
__Vertigo/Dizziness
EXERCISE
__None
__Moderate
__Daily
__Heavy
Date
________________
________________
________________
________________
regarding our services. The best health services are based on a friendly, mutual understanding between
provider and patient.
e with the business manager. If
account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection
agency fees, interest charges and any other expenses incurred in collecting your account.
r to release any information
required to process insurance claims.
e this form was completed correctly to the best of my knowledge and understand it is my responsibility to
inform this office of any changes to the information I have provided.
Signature: _______________________________________________ Print Name: _____________________________________
Relationship to Patient: _________________________________
Date: ________/_________/______
Max Medical Care
3900 NW 79 Avenue #825, Doral, FL 33166
Releasing Information / Patients Rights and
Acknowledgement of Receipt of Notice of Privacy Practices
The Department of Health and Human Services has established a “Privacy Rule” to help insure that personal health care
information is protected for privacy and is only to be used or shared in the minimum necessary fashion. Healthcare
providers are to obtain their patient’s consent for uses and disclosure of health information about the patient to carry
out treatment, payment, or health care operations. By signing this consent, you understand that your physician may
need to provide necessary medical information to other appropriate physicians, pharmacies, hospitals, insurance
companies, laboratories, and billing agencies. Refusing to consent to the use or disclosure of your personal health
information prohibits the doctor from billing for their services; scheduling your care at a hospital; or calling in a
prescription to a pharmacy; or medical need. Under this law we have the right to refuse to treat you should you choose
to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some
future time you may request to refuse all or part of your PHI. You may not revoke any actions that have already been
taken which relied on this or a previously signed consent. If you have any objections to this form, please ask to speak
with our Office Manager. Patient Consent for use and disclosure of Protected Health Information as required and/or
permitted by law.
_____________________________________
Patient’s Name
_______________________________________________
Patient or Legal Representative Signature
________________
Date
And I also acknowledge that I have been provided with the “Notice Of Privacy Practices”
Compliance Assurance Notification for Our Patient’s
The misuse of PHI has been identified as a national problem causing inconvenience, aggravation, and money.We want
you to know that all of our employees, managers, and doctors continually undergo training so that they may understand
and comply with government regulations regarding HIPAA with particular emphasis on the “Privacy Rule”. We strive to
achieve the very highest standards of ethics and integrity in performing service for our patients. It is our policy to
properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to
ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of
this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of
PHI. We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients
without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so,
we welcome your imput regarding any service problem so that we may remedy the situation promptly.
AUTHORIZATION AND CONSENT FOR CHIROPRACTIC MEDICAL TREATMENT, AND/OR PHYSICAL THERAPY,
AND/OR MASSAGE THERAPY
I, the undersigned patient of this office, hereby authorize the physicians at MAX MEDICAL CARE (and whomever
they designate as their assistants) to administer such treatments as is reasonable and necessary. These include
treatments such as manipulations, adjustments, physical therapy, diagnostic testing, additional therapy, procedures
which may arise during the course of treatment based upon the finding of said treatment, or in the treatment of a new
injury, condition or problem
I, also have been advised and understand and has been explained to me that although uncommon, there is a risk of
complications that occur with any treatment, including chiropractic, therapy and other physical and medical treatment
received by the physicians and therapists in this office. These include, but not necessarily limited to, muscle soreness,
strains, aggravation of pre-existing injuries, infections, headaches, strokes, dislocations, fractures, and other
complications related to the care and treatment received from the clinicians of this office.
This authorization applies to any location where services are rendered, whether they are administered in a clinical
setting or other venue. I recognize the limitation of certain venues and thereby agree to follow through with the
doctor’s recommendations regardless of the location, unless I waive the rights to such procedures and therapy.
I hereby certify that I have read and fully understand the above Authorization and Consent for Chiropractic
Medical Treatment. The reason why the above-named treatment is considered necessary, its advantages and
disadvantages, possible complications, some of which are listed above, if any, as well as a possible alternative modes of
treatment which have been explained to me by the physicians of MAX MEDICAL CARE.
I also certify that it has been advised to me and understand that there are no guarantees or assurances as to the
results that may be obtained from the care and treatment rendered by the physicians and therapists of the above
named entities. I also acknowledge that I have notified the physician promptly if there are any questions, concerns,
complication of problems relating to my care, and further understand that compliance with all recommended care is
important to achiev3ing desired results.
Date:
__
Signed:
Witness:
Consent to Treat a Minor
I hereby authorize the physicians of MAX MEDICAL CARE and whomever they may designate as their
assistants to administer treatment as they deem necessary to my son/daughter or other
____________________________.
Patient’s Name:
Signature of Parent/Legal Guardian:
Relationship to Patient: ________________________________
Date:_______________________
Patient Request for Confidential Communications of Protected Health Information
The Health Insurance Portability Act of 1996 (“HIPAA”) provides you the right to request that MAX MEDICAL CARE (MMC)
communicate with you about your health information at an alternative address or phone number, or by an alternative means (for
example, by email) that is more confidential for you. MMC must accommodate your request if it is reasonable. CHC may require you
to specify an alternative address or other method of contact before providing the requested accommodation. If your request is
accepted, the Medical Center will make every attempt to communicate with you in the manner you have requested. Your election
will remain in effect until you have instructed us in writing to change the manner of communication.
To request confidential communications, please complete the form below and send to:
MAX MEDICAL CARE
3900 NW 79 AVE #825, DORAL, FL 33166
Patient Name: _______________________________________________ Telephone #: _____________________________
(Print)
Address: __________________________________________City:_________________State:______Zip:_______________
Describe the alternative means of communication you are requesting:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
I am requesting that MMC., communicate with me by an alternative means or at an alternative address or phone number that is
more confidential for me. I understand that the Medical Center will not accommodate unreasonable requests.
______________________________________________________
Signature of Patient or Legal Representative
REMINDER:
Date Signed ________ /________ /_________
*May be requested to show proof of representative status
If the alternative address selected by patient is an e-mail, then E-Mail Consent Form MUST be completed.
E-Mail Consent Form
Purpose: This form is used to obtain your consent to communicate with you by email regarding your Protected Health Information (PHI).
MAX MEDICAL CARE., (MMC) offers patients the opportunity to communicate by e-mail. Transmitting patient information by e-mail
has a number of risks that patients should consider before granting consent to use e-mail for these purposes. MMC will use
reasonable means to protect the security and confidentiality of e-mail information sent and received. However, MMC cannot
guarantee the security and confidentiality of email communication and will not be liable for inadvertent disclosure of confidential
information.
Patient’s Acknowledgment and Agreement
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with communication of
e-mail between MMC and me and consent to the conditions outlined herein. Any questions I may have had were answered.
I agree and consent that MMC may communicate with me regarding my protected health information by e-mail.
My Consented E-Mail Address is : ________________________________________________________________________________
____________________________________________________________________________________________________________
___________________________________________________
Date Signed: _______/________/_________
Signature of Patient or Legal Representative * May be requested to show proof of representative status
Office Use:
Received: ____/_____/_____
Completed: ____/_____/_____
Initials: __________
MAX MEDICAL CARE
Tax ID 46-5177423
Patient Name:
Assignment of Insurance Benefits:
I hereby authorize payment to be made directly to MAX MEDICAL CARE. of all benefits which may be due
and payable under insurance coverage for the above named patient. I authorize utilization of this
application or copies thereof for the purpose of processing claims and effecting payments. I further
acknowledge that this assignment of benefits does not in any way relieve me of liability and that I will
remain financially responsible to MAX MEDICAL CARE.
Furthermore, I hereby irrevocably assign to MAX MEDICAL CARE the rights and benefits under any
policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for
any service and or changes provided by MAX MEDICAL CARE.
Authorization To Release Medical Record Information:
I hereby authorize to disclose all or any part of the medical records on the above name patient to such
insurance companies, organizations, or agencies as may be responsible for payment of services rendered
by MAX MEDICAL CARE. This authorization is given full knowledge that such disclosure may contain
information of a confidential nature and may result in a denial of insurance coverage for services
rendered by said MAX MEDICAL CARE.
The undersigned certifies that he/ she has read and understands each of the above paragraphs and is the
patient or responsible party with the power to execute this document and accept these terms.
Signature of patient or responsible party:
__________
_____________
Date:_____/______/____
Relationship to Patient:__________________________
Signature of witness:
Date:_____/_____/_____