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Pediatric Form: Please fill out everything completely and to the best of your knowledge.
* Required
Child's Legal Name
*
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Preferred Name:
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Parent/Guardian’s Name:
*
Your answer
Home Phone:
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Cell Phone:
*
Your answer
Address:
*
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City, State, Zip:
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Sex:
*
Male
Female
Required
Date of Birth:
*
MM
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DD
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YYYY
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?
*
No
Yes
If yes; when?
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Appointment Reminders:
Choose
Email Reminders
Call my home
Call my cell
Text my cell
If you chose "text cell", please select your carrier:
AT&T
Bluegrass Cellular
Boost
Cingular
Sprint
TMobile
Verizon
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
Leave message with detailed info
Leave message with call back number only
Cell Phone
Leave message with detailed info
Leave message with call back number only
Work Phone
Leave message with detailed info
Leave message with call back number only
Written
OK to mail to home address
OK to e-mail
Belcher Chiropractic May Speak With/Regarding:
Parent
Appointment Times
Financial Balance
Condition Status
Other Guardian
(Type their name in Other)
Appointment Times
Financial Balance
Condition Status
Other:
Friend
(Type their name in Other)
Appointment Times
Financial Balance
Condition Status
Other:
Attorney/Insurance Agent
Appointment Times
Financial Balance
Condition Status
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
Your answer
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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