Dr. Trent A. Gusso
Welcome to Our Office!
(Please Print) Date: __________ Name:___________________________________________Address:_____________________________________
City, State, Zip:_______________________________________Home phone:______________________________
Social Security #:____________________Birthday:_________________Age:_______Height:_______Weight:______
No. of Children__________Marital Status – M S D W_______Spouse’s Name or Parent_____________
Your Occupation________________________Employed By______________________Work Phone:___________
Address__________________________________City, State, Zip_________________________
Who may we thank for referring you to our office?__________________________
Have you ever had Chiropractic Care before?_____________If so, when?_______________________
List your complaints in order of severity:
1._______________________________________For how long?_________________________________
2._______________________________________For how long?_________________________________
3._______________________________________For how long?_________________________________
List other doctors consulted for these conditions:
Is this injury or illness work-related?__________Have you reported it to your employer?______________________
Is this injury of illness related to an automobile accident?___________(if yes, name of)
Your Auto Ins. Co._______________________Policy #____________________Claim #____________________
NOTICE: Not all patients require x-rays to determine or verify a diagnosis, type of treatment or length of treatment; if your examination warrants X-ray analysis the following office policy prevails: (1) All first visit charges with or without X-rays are payable when service is rendered. (2) The fee paid for treatment X-rays is for analysis only. The film itself is the property of this office and remains part of your permanent records.
Method of payment you plan to use to take care of today’s charges:
⃝Check ⃝Cash ⃝MasterCard ⃝Visa ⃝Discover
Major Medical Insurance Co.__________________________________________________
Group Number________________________________I.D. Number____________________________
Any Other Health Insurance Co.______________________________________________________
Group Number_________________________________I.D. Number___________________________
Surgery (Please include all surgery)
ARE YOU NOW OR HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING:
Nervousness Heart attack
Numbness of pain in arms/legs/hands Diabetes
Pregnant at this time Sinus
Pain between shoulders Stiff neck
Spinal curvature Backache
Heart disease Swollen joints
High blood pressure
Please rate your pain: 0 (Absent) to 10 (Extreme)
Getting worse Getting better Staying the same
X-RAY CONFIRMATION: This is to confirm that I have been advised by this office that x-rays can be hazardous to an unborn child. At this time, to the best of my knowledge, I am not pregnant, and I consent to spinographic pictures.
CONSENT TO TREAT A MINOR CHILD: I hereby authorize this office to administer chiropractic as deemed necessary for my child.
Signature_________________________________________(Parent/Legal Guardian) Date__________________
I understand and agree that health and accident insurance policies are an arrangement between and insurance carrier and myself. Furthermore, I understand that the Doctor’s Office will process any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor’s Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment.
AUTHORIZATION TO RELEASE INFORMATION
To: Trent A. Gusso, D.C.
You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you, and I hereby release you of any consequences thereof.