Forms

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

About this Patient

About the Spouse 

Employer Information

Is this visit related to an auto accident?

Reason for this Visit

What type of complaint?*
Please select at least one option
How did this injury or condition occur?*
Please select one option
What is frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
What is the VAS? Rate your pain on a scale of 1-10 (10 being worst)*
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What is symptom relieved by?*
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Any past episodes of this complaint?*
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Has patient received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
What activity of daily living most affected?*
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What does patient have difficulty performing due to this specific complaint? (Choose all the apply)*
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What musculoskeletal issues do you have?*
Please select at least one option
What Head and ENT issues do you have?*
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What cardiovascular issues do you have?*
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What gastrointestinal issues do you have?*
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What genitourinary issues do you have?*
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What endocrine issues do you have?*
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What dermatological or hematopoietic issues do you have?*
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Please select all that describe your surgical history*
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Drugs and medications being taken?*
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Past history of accidents or trauma?*
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Patient's Immediate Family Health History?
Type of social habits?
Type of exercise routine?
Type of diet and nutrition?
What was the cause of the injury?*
Please select one option
What was your position in vehicle?*
Please select one option
Were you restrained or unrestrained?*
Please select one option
Did the airbag deploy?*
Please select one option
Where was the patient looking at the time of the impact?*
Please select one option
Did the patient contact interior of vehicle?*
Please select one option
What part of body came in contact with interior?*
Please select at least one option
Where in interior of vehicle was contacted?*
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Did you (or the patient) receive an injury to the head?*
Please select one option
Did the patient lose consciousness?*
Please select one option
What was patient vehicle impact?*
Please select at least one option
What was patient vehicle movement?*
Please select at least one option
What was the estimated speed of the vehicle patient was driving in?*
Please select one option
What is patient vehicle damage?*
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What was other vehicle's movement?*
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What was the estimated speed of other vehicle?*
Please select one option
How much damage is estimated to other vehicle?*
Please select one option
Was the patient vehicle towed from the scene?*
Please select one option
Were police at scene?*
Please select at least one option
Was there an accident report?*
Please select one option
Was EMS at the Scene?*
Please select one option
Did patient go to hospital?*
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Has patient received any treatment since the accident?*
Please select at least one option
Describe the discomfort felt at the time of the accident:*
Please select at least one option
Where were symptoms felt at the time of the accident?*
Please select at least one option
Additional Symptoms at the time of the accident (supplemental)?*
Please select at least one option
Status of symptoms since accident?*
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Experience with Chiropractic 

Does your family have any history of the following:*
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Awareness of Chiropractic Principles 
Were you aware that...

Doctors of Chiropractic work with the nervous system?*
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The nervous system controls all bodily functions and systems?*
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Chiropractic is the largest natural healing profession in the world?*
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If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*
Please select one option

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

FOR WOMEN ONLY:

Who should receive bills for payment on your account?*
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Ownership of X-ray Films


It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

Emergency Contact

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Missed Appointments


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Today's payment will be made by:*
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Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Thank you for taking the time to fill out this form.

ASH Chiropractic & Wellness

3622 Williams Dr Bldg 5,
Georgetown, TX 78628

Monday  

8:30 am - 12:00 pm

2:30 pm - 5:30 pm

Tuesday  

8:30 am - 12:00 pm

Wednesday  

8:30 am - 12:00 pm

2:30 pm - 5:30 pm

Thursday  

8:30 am - 12:00 pm

2:30 pm - 5:30 pm

Friday  

8:30 am - 12:00 pm

Saturday  

Closed

Sunday  

Closed

Location

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Please do not submit any Protected Health Information (PHI).