Intake Form

Patient's Name*
First Middle Last
- Address*
  Street Address Address Line 2 City State ZIP Code
- Mailing Address (if different)
  Street Address Address Line 2 City State ZIP Code
Patient's gender*
- Home Phone
- Cell Phone
- Number of Children
- Is patient a minor?*
- Date of Birth*
- Referred to our clinic by
- Relationship Status*
Parent or Guardian*
First MI Last
Email
Enter Email Confirm Email
- Are you employed?*
- Does your pain relate to a Workers Comp claim?*
Where are you employed?*
Employer's Name*
First Last
Employment Phone*
Employment Address*
Street Address Address Line 2 City State ZIP Code
Does your pain relate to a motor vehicle accident?*
Emergency Contact
Name
First MI Last
Relationship
Primary Phone
Secondary Phone
Authorization for Release of Your Patient Information: (optional)
Name
First MI Last
Relationship
Please mark the exact location of your pain or symptoms on the diagrams below*
Click or tap the X to reset
Please mark the exact location of your pain or symptoms on the diagrams below*
Click or tap the X to reset

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Workers Comp Claim Form

We are very pleased you have chosen our doctors to get you back on the path to wellness after your Workers Comp injury.

We will be glad to forward your treatment plan and billing to your employer’s insurance carrier. For us to do this it will be necessary to provide us with the following information in order to be seen on your appointment date.

Notify your employer that you will be seeing our doctors.
Employer HR Contact Name*
First Last
HR Contact Phone*
Name of the insurance company.*
Address of your insurance company*
Street Address Address Line 2 City State ZIP Code
Insurance Phone*
Name of the person handling your claim*
First Last
- Their phone number*
- 6) Claim Number*

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Motor Vehicle Treatment Form

We are very pleased you have chosen our doctors to get you back on the path to wellness after your automobile accident.

It is not our clinic policy to file automobile medical claims on a third-party policy, regardless of which party is at fault. We will be glad to forward your treatment plan and billing to YOUR automobile insurance company. For us to do this it will be necessary to provide us with the following information in order to be seen on your appointment date
Name of your insurance company*
Medical claim number you were given when you filed your medical claim with your automobile insurance company*
Name of the person handling your medical claim*
First Last
Phone number of the person handling your claim to whom claims and bills will be sent by our clinic*

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- Major Complaint(s):*
  Please describe your major complaint(s) and describe the frequency and nature of your pain. For example: dull, sharp, constant, off and on, when standing, when sitting, etc.
- When did your condition first begin and what caused it?*
- Have you ever had this problem or similar problem before?*
- If yes, please explain*
- Have you seen another chiropractic physician for this complaint?*
- If yes, who?*
- What was their diagnosis?*
- Have you seen another medical physician for this complaint?*
- If yes, who?*
- What treatment have you had for this condition?*
- What was their diagnosis?*
- Is your condition getting better, worse, or staying the same?*
- What makes your condition worse?
- What makes your condition better?
- Have you ever been involved in an automobile accident?*
- If yes, when and where?*
- What surgeries have you had? Include Date:*
- Please list drugs you now take:
- Please list vitamins, minerals, supplements, and/or herbs you now take:
- Other conditions or additional comments:
Signature of Patient*

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand and agree that the health and accident insurance policies are an arrangement between me and my insurance company. I understand that this clinic will file insurance forms to assist me in obtaining payment from the insurance company and that any amount authorized to be paid directly to this clinic will be credited to my account on receipt. I also authorize the release of any needed information. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable within 30 days. I also understand that I am giving my consent to be treated.

Scheduled appointments that are not kept by the patient with no prior notification of cancellation may be subject to a $25 charge. Returned checks for insufficient funds may be charged $30 per incident.
Signature of Parent or Guardian*

I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I understand and agree that the health and accident insurance policies are an arrangement between me and my insurance company. I understand that this clinic will file insurance forms to assist me in obtaining payment from the insurance company and that any amount authorized to be paid directly to this clinic will be credited to my account on receipt. I also authorize the release of any needed information. I understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable within 30 days. I also understand that I am giving my consent to be treated.

Scheduled appointments that are not kept by the patient with no prior notification of cancellation may be subject to a $25 charge. Returned checks for insufficient funds may be charged $30 per incident.

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Insurance Benefit Information
Insurance Information: Please upload a FRONT AND BACK copy of your medical health insurance card(s) in addition to a copy of your driver's license. OR, please provide the following information: A copy of your insurance card (s) and driver's license will be made when you arrive for your appointment.
File(s)
Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.
Please remember to scan the front and back of your insurance card!!
You can scan or photograph your driver's license and insurance card(s) and upload them here. jpg, gif, png, pdf file types only please.
OR, please provide the following information: A copy of your insurance card (s) and driver's license will be made when you arrive for your appointment.
- Insurance Company Name
- Provider Customer Service Phone
- Member ID Number
- Group Number
Secondary Insurance Provider's Information
- Insurance Company Name
- Provider Customer Service Phone
- Member ID Number
- Group Number

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Family and Social History: Your History
- 1. Any history of lung disease?*
- Explain:*
- 2. Any history of bowel problems?*
- Explain:*
- 3. Any history of genito/urinary problems?*
- Explain:*
- 4. Any history of cardiovascular disease?*
- Explain:*
- 5. Any history of neurological diseases?*
- Explain:*
- 6. Any history of cancer?*
- Where:*
- 7. Do you use tobacco products?*
- How much?*
- 8. Do you drink alcohol?*
- How much?*
- 9. Any history of accident other than automobile?*
- Explain*
- 10. Any drug, vitamin or herbal allergies?*
- Explain*
Family and Social History: Your Family History
- 1. History of diabetes in your family?*
- Explain*
- 2. History of heart disease in your family?*
- Explain*
- 3. History of cancer in your family?*
- Explain*
- 4. History of arthritis in your family?*
- Explain*

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Patient Consent for Use and Disclosure Of Protected Health Information
I hereby give my consent for Little Rock Chiropractic Clinic, P.A. (hereinafter referred to as “LRCC”) to use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO).

LRCC's Notice of Privacy Practices provides a more complete description of such uses and disclosures. I have the right to review the Notice of Privacy Practices prior to signing this consent. A copy of this Notice is available upon request to Dr. Richard L. Riley or Denise Moix, our Privacy Officers, or any other LRCC staff member.

LRCC reserves the right to revise its Notice of Privacy Practices at any time and agrees to provide me a revised copy upon my request to LRCC.

With this consent, the LRCC may call (or text message) my home or other designated phone number on file and leave a message on voice mail or in person in reference to any items that assist LRCC in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory results among others.

With this consent, LRCC may mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as patient statements.

With this consent, LRCC may e-mail to my home or other designated location on file any items that assist LRCC in carrying out TPO, such as appointment reminders and patient statements.

I have the right to request that LRCC restrict how it uses or discloses my PHI to carry out TPO. However, LRCC is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to LRCC's use and disclosure of my PHI to carry out TPO.

I may revoke my consent in writing except to the extent that LRCC has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, LRCC may decline to provide treatment to me as permitted by Section 164.506 of the Code of Federal Regulations.

Today's Date: 09/19/2024
Print Patient’s Name*
First MI Last
Print Name of Legal Guardian, if applicable
First MI Last
Signature*
Consent
I have been given and am in receipt of LRCC’s Notice of Privacy Practices.
(please initial)*
Consent 2
I do not wish to receive a copy of LRCC’s Notice of Privacy Practices.
(please initial)*

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FORMS

Application for Chiropractic Treatment

Step 1 of 9

Emergency Contact

Authorization for Release of Your Patient Information: (optional)

Workers Comp Claim Form

Motor Vehicle Treatment Form

Insurance Benefit Information

Secondary Insurance Provider's Information

Family and Social History: Your History

Family and Social History: Your Family History

System Review and Past Medical History

Patient Consent for Use and Disclosure Of Protected Health Information

Oswestry Disability Questionnaire