Integrity Chiropractic Intake Form
For New Patients only/All information kept confidential
Email address *
Last Name, First Name *
Your answer
Date of Birth *
Your answer
Gender
Age *
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Height *
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Weight *
Your answer
Occupation
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Marital Status *
Address (Include City) *
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Zip Code *
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Best Contact Number *
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How do you prefer we communicate with you (check any that apply)? *
Required
Emergency Contact Name & Phone #: *
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Do you have kids? *
How did you hear about us? *
Your answer
What is the reason for seeking Chiropractic Care? (i.e. back, neck, shoulder, foot pain, wellness/lifestyle care, etc) *
Your answer
How long has this been going on? *
Your answer
Check any below that apply to your goals while you are under Chiropractic Care. *
Required
How is this affecting your life? (physically, socially, family life, concern for future health) *
Your answer
What is your understanding of Chiropractic? (alignment of spine, overall health, part of a healthy lifestyle, etc.)
Your answer
Previous Chiropractic Care? *
If yes, when was your last adjustment?
Your answer
Please check any of the following you are experiencing in your life (past or current):
If you are currently taking any prescription medications, please list here.
Your answer
Are you Pregnant/Is Wife or Partner Pregnant (if applicable)?
Have you ever had or currently have any of the following? Check all that apply
If you checked stroke - please provide date of occurrence:
Your answer
Have you had MRI’s, X-Rays, CT scans in the past year? If yes, please explain.
Your answer
Have you had any major sicknesses, been unconscious, or extended hospitalizations? If yes, please explain:
Your answer
What are the healthiest habits you currently have?
Your answer
As of 1/1/2018, we are in a few insurance networks. Please note, if we are filing insurance on your behalf, the patient is ultimately responsible for payment. If for any reason your insurance claim is denied, you will be billed for services rendered. In the end, your insurance benefits and health care costs are the patient's responsibility. I have read and agree to the above statement. *
Purpose — Objective – Approach – Consent of Treatment - Policies
We all desire to be well as quickly as possible, and I will do my best to facilitate this process along the way. Please do your part as well, meaning move well, eat well, drink plenty of water, everyday. Know that the nervous system, the body, you, need time to heal. If you’ve had a condition a while, it will take time to reach resolution.

The material risks inherent in chiropractic adjustment.
As with any healthcare procedure, there are certain complications, which may arise during chiropractic manipulation. Those complications include: fractures, disc injuries, dislocations, muscle strain, Horner's syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke, especially in patients who smoke cigarettes. Some patients will feel some stiffness and soreness following the first few days of treatment.

AUTHORIZATION AND RELEASE (where applicable): I authorize payment of insurance benefits directly to the chiropractor or chiropractic office. I authorize the doctor to release all information necessary to communicate with personal physicians and other healthcare providers and payors and to secure the payment of benefits. I understand that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.
The patient understands and agrees to allow Hyre Chiropractic to use their Patient Health Information for the purposes of treatment, payment, healthcare operations, and coordination of care. We want you to know how your Patient Health Information is going to be used in this office and your rights concerning those records. If there is anyone you do not want to receive your medical records, please inform our office.

I give my permission to my chiropractor at Hyre Chiropractic to provide Chiropractic Care to me. I have also read the statements above, and understand their contents. I understand that the spinal adjustments offered by Dr. Hyre, are not a replacement for any form of diagnosis or treatment provided by other types of practitioners.

24 HOUR CANCELLATION POLICY:
A cancellation fee equal to the value of your visit will be assessed if 24 hours notice is not provided.

CREDIT CARD PROCESSING FEE:
There is a 2.75% fee added to all credit card transactions.

THE PATIENT/DOCTOR RELATIONSHIP:
The practice of chiropractic care is that of a personal one, over time, Dr. Hyre and the patient will create and have a very special patient/doctor relationship. In the course of nearly 10 years of practice, her policy is: she does not have personal relationships with clients outside the office. This is due to strict regulations and the chiropractic code of ethics to protect you as a client. As much as Dr. Hyre would love to accept patient offers/invitations to social events/holiday gatherings, coffee, etc. she is not able to.

Medicare Eligible Patients - PLEASE READ
Dr. Hyre is not a medicare provider, which means we do not file medicare claims of any kind. We ONLY provide what is considered maintenance/wellness care to medicare patients. If you are a medicare eligible patient and feel your care may be what’s considered active treatment - meaning it resulted from an injury or you’re in an intolerable amount of pain, we would recommend you find a chiropractor who is enrolled as a medicare provider. Further, you may make an appointment but if through the physical exam Dr. Hyre’s expert opinion is that your symptoms require x-rays or further diagnostic testing, she will refer you to a specialist who can help you. If you are unsure - as this is sometimes difficult for the patient to determine, please give us a call, we are happy to go over what we do and don’t do in our office and how we can best help you.

Please note: Insurance clients (including health insurance, work accidents and personal injury cases) are billed at a higher standard rate than our cash/out of pocket rates. These are national market rates for the Portland/Vancouver Region. In addition, car accidents/work injuries/personal injury cases are quadruple the amount of administrative and professional work. These cases require a signed lien between the patient, doctor, and lawyer (if applicable). Our complete fee schedule which includes all rates is available upon request. If you have been in a recent car accident or work injury - please let us know.

eSignature (Print Full Name) *
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Today's Date: (MM/DD/YY) *
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If under 18 - Parent's name, email and phone number (so that we can obtain consent)
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"Never Underestimate the Power of an Adjustment!"
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