Dr. Trent A. Gusso

Welcome to Our Office!

(Please Print)                                                                                                                            Date: __________                                            Name:___________________________________________Address:_____________________________________                     

City, State, Zip:_______________________________________Home phone:______________________________                                                             

E-mail:_______________________________________________Cell 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:

1.______________________________________Address:__________________________                                                                                                                                                              

2.______________________________________Address:__________________________          

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 #____________________                                            

Address____________________________________Agent’s Name__________________________                                                                                                             

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___________________________                                                               

Medicare__________________________________Medicare Number___________________________________                                                                                      

Surgery (Please include all surgery)

1.__________________________________________When____________________________________                                                                                                                           

2.__________________________________________When_____________________________________                                                                                                                          

3.__________________________________________When_____________________________________                                                                                                                        

ARE YOU NOW OR HAVE YOU SUFFERED FROM ANY OF THE FOLLOWING:

Stroke                                                                        Headache

Fatigue                                                                       Shingles

Migraine                                                                    Dizziness

Nervousness                                                             Heart attack

Arthritis                                                                      Cancer

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

 

0________________5________________10               

Please rate your pain: 0 (Absent) to 10 (Extreme)

Are symptoms

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.

 Signature___________________________________________________Date______________________         

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__________________                           

FINANCIAL/INSURANCE POLICY:

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.

Signature_______________________________________________________Date_________________________

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.                  

Signature________________________________________________________Date_____________________

Witness__________________________________________________________________________________