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Pediatric Form: Please fill out everything completely and to the best of your knowledge.
Child's Legal Name *
Preferred Name:
Parent/Guardian’s Name: *
Home Phone:
Cell Phone: *
Address: *
City, State, Zip:
Sex: *
Required
Date of Birth: *
MM
/
DD
/
YYYY
Email Address:
Where did you hear about our office?:
Medical Doctor or Office:
Approx last visit:
Has this child received chiropractic care before? *
If yes; when?
Appointment Reminders:
If you chose "text cell", please select your carrier:
Clear selection
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
Cell Phone
Work Phone
Written
Belcher Chiropractic May Speak With/Regarding:
Parent
Other Guardian
(Type their name in Other)
Friend
(Type their name in Other)
Attorney/Insurance Agent
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
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.
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