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    Patient Information

    4640 Hypoluxo Rd., Ste.2, Lake Worth, FL 33463 (561) 296-1715 fax: (561) 296-1716 www.AHCPB.com

    Accident Information

    Insurance Information

    PLEASE PROVIDE THIS OFFICE WITH A COPY OF YOUR INSURANCE CARD(S)

    Assignment and Release (insured patients)

    I certify that I (or my dependent) have insurance coverage with and I AUTHORJZE, REQUEST AND ASSIGN MY INSURANCE COMPANY TO PAY DIRECTLY TO THE PHYSICIAN/MEDICAL PRACTICE, INSURANCE BENEFITSOTHERWISE PAYABLE TO ME. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary, including the diagnosis and the records of any exam or treatment rendered to me, in order to secure the payment of benefits. I authorize the use of this signature on all insurance claims, including electronic submissions.

    X-ray Questionnaire: For women only

    Our consultation and examination may indicate that x-rays are neces ary to accurately diagnose and analyze your condition. Should x-rays be necessary we would like to confirm that you are not pregnant at this time.

    Health Histroy

    CHECK ANY OF THE FOLLOWING PAST MEDICAL PROBLEMS YOU HAVE HAD:

    Now

    Past

    Now

    Past

    Now

    Past

    Diabetes

    Thyroid Disease

    Osteoporosis

    Ulcers

    Goiter

    Polio

    Gastric Reflux/ GERO

    Kidney Disease

    Fractures

    Colitis/ IBD

    Pneumonia

    Multiple Sclerosis

    Hea11 Disease

    Tuberculosis

    Parkinson's

    Cone.estive Heart Disease

    Influenza

    Prostate Problems

    Blood Clots (DVT)

    Asthma

    Immune Disorder

    Peripheral Vascular Disease

    Emphysema

    Migraine Headaches

    Stroke

    COPD

    Seizure Disorder

    Pacemaker

    Bronchitis

    AIDS/HIV

    High Cholesterol

    Liver Disease

    Chemical Dependency

    High Blood Pressure

    Osteoarthritis

    Mental Disorders

    Bleedin Disorder

    Rheumatoid Arthritis

    Depression

    Anemia

    Gout

    Alcoholism

    CHECK ANY OF THE FOLLOWING PAST MEDICAL PROBLEMS YOU HAVE HAD:

    GENERAL

    EYES

    HEMATOLOGIC/ LYMPH

    SKIN

    ENDOCRINE

    MUSCULO-SKELETAL

    GASTROINTESTINAL

    CARDIOVASCULAR

    EAR/NOSF/THROAT

    GENITOURINARY

    NERVOUS SYSTEM

    RESPIRATION

    PSYCHIATRIC

    FEMALES ONLY

    cups/day

    packs/day

    CONSENT TO CARE

    You are the decision maker for your health care. Part of our role is to provide you with inf01mation to assist you in making informed choices. This process is often referred to as "infonned consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care. It is important that you understand, as with all health care approaches, results are not guaranteed, and there is no promise to cure.

    A patient coming to the doctor gives him/ her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. We may conduct some diagnostic or examination procedures and clinical procedures if indicated, which rarely may cause some discomfort. These are usually beneficial and seldom cause any problem. In rare cases underlying physical defects, defonnities or pathologies, may render the patient susceptible for injury. The doctor or healthcare provider, of course, will not provide specific healthcare, if he/ she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/ she is suffermg from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician.

    Physical therapy is to treat disease, injury and disability by examination, evaluation, diagnosis, prognosis and intervention by use of rehabilitative procedures, mobilization, massage, exercises, and physical agents to aid the patient in achieving their maximum potential within their capabilities and to accelerate convalescence and reduce the length of functional recovery. All procedures will be thoroughly explained to you before you are asked to perform them.

    Chiropractic care involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. As with all types of health care interventions, there are some risks to care, including, but not I im ited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, burns and/or scarring from electrical stimulation and from hot or cold therapies, including but not limited to hot packs and ice, fractures (broken bones), disc injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as an "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to a stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an aI1ery to be more susceptible to dissection.

    Response to care and interventions varies from person to person; hence, it is not possible to accurately predict your response to a specific modality, procedure, exercise protocol, or treatment. Advanced Healthcare of the Palm Beaches, Inc. does not guarantee what your reaction will be to a specific treatment, nor does it guarantee that the treatment will help resolve the condition that you are seeking treatment for. Furthennore, there is a possibility that the care may result in aggravation of existing symptoms and may cause pain or injury.

    It is your right to decline any part of your treatment at any time before or during treatment, should you feel any discomfort or pain or have other unresolved concerns. It is your right to ask your doctor or healthcare provider about the treatment they have planned based on your individual history, diagnosis, symptoms, and examination results. Consequently, it is your right to discuss the potential risks and benefits involved in your treatment.

    I have read, or have had read to me, the above consent I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content, and by signing below, I agree with the current or future recommendation to receive treatment as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek treatment from this office.

    I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

    PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    I acknowledge that I have reviewed the Notice of Privacy Practices of ADVANCED HEALTHCARE OF
    THE PALM BEACHES, (AHC).

    Please initial below:


    Signature of Patient/Guardian


    Date


    Witness (Office Staff)


    Date