Pediatric Form: Please fill out everything completely and to the best of your knowledge.

Child's Legal Name

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Preferred Name:

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Parent/Guardian’s Name:

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Home Phone:

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Cell Phone:

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Address:

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City, State, Zip:

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Sex:

Male
Female

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Date of Birth:

Email Address:

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Where did you hear about our office?:

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Medical Doctor or Office:

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Approx last visit:

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Has this child received chiropractic care before?

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If yes; when?

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Appointment Reminders:

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HIPAA PATIENT INFORMATION RELEASE FORM:

In general, the HIPAA privacy rule gives individuals the right to request confidential communications or that a communication of private health information be made by alternative means, such as sending correspondence to the patient’s office instead of the their home. Occasionally our office will send out greeting cards, reminder postcards, call and/or email you regarding an appointment, etc. Please let us know which form(s) of communication you would prefer to be contacted by. By signing this form, I am acknowledging that I have been notified of the Privacy Practices utilized in this office and may request a copy of such document. Please check all that apply below.

Home Phone

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Leave message with call back number only

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Cell Phone

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Leave message with call back number only

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Work Phone

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Leave message with call back number only

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Written

OK to mail to home address
OK to e-mail

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Belcher Chiropractic May Speak With/Regarding:

Parent

Appointment Times
Financial Balance
Condition Status

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Other Guardian

(Type their name in Other)

Appointment Times
Financial Balance
Condition Status
Other:

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Friend

(Type their name in Other)

Appointment Times
Financial Balance
Condition Status
Other:

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Attorney/Insurance Agent

Appointment Times
Financial Balance
Condition Status

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I hereby authorize Aaron Belcher, D.C. to disclose any information that may be required by their examination or other means of my physical or mental condition, financial situation or appointment times. If this section is not completed, we will only be able to discuss your case with you and you only.

Initial & Date DM 11/24/15

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