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Revelation Chiropractic

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Revelation Chiropractic
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  • About Us
  • Your First Visit
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    • New Patient Form
    • Reactivation Patient Paperwork
    • Auto Injury Patient Intake
    • Patient Progress Evaluation
    • Testimonial Submission
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  • Contact Us

Auto Injury Patient Intake

Auto Injury Patient Paperwork

  • AUTO INJURY INFORMATION

  • Date Format: MM slash DD slash YYYY
  • (Or guardian's cell if patient is a minor)
  • (Or guardian's email if patient is a minor) *Email is required because we will send you your scan and evaluation results*
  • (For children, enter parent/guardian's email above) *Email is required because we will send you your scan and evaluation results after your appointment.*
  • (For minors who do not have an occupation, put "child")
  • AUTO INJURY QUESTIONNAIRE

  • (optional)
  • Date Format: MM slash DD slash YYYY
  • :
  • Please enter a number greater than or equal to 1.
  • Example: Toyota, Honda, Ford...
  • Example: Camry, CR-V, F-150....
  • Enter '0' if you are unsure of a dollar amount.
  • PURPOSE OF THIS VISIT

  • Date Format: MM slash DD slash YYYY
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • SYMPTOMS QUESTIONNAIRE

  • This section is focused on misalignment of the neck region.
  • This section is focused on misalignment of the mid-back region.
  • This section is focused on misalignment of the low back region.
  • This section is focused on misalignment of the pelvis (sacrum).
  • EXPERIENCE WITH CHIROPRACTIC CARE

  • Date Format: MM slash DD slash YYYY
  • HEALTH LIFESTYLE

  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • *Put "N/A" if not applicable
  • TERMS OF ACCEPTANCE & CONSENT TO CARE

  • TERMS OF ACCEPTANCE When a person seeks chiropractic health care and is accepted for such care, it is essential for both parties to be working towards the same objective. We have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine. Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express it's maximum health potential. We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Regardless of what a disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body's innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations. N01E: It is understood and agreed the amount paid to Revelation Chiropractic for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office.
  • CONSENT TO CARE I do hereby authorize the doctors of Revelation Chiropractic to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care. Furthermore, I authorize and agree to allow Revelation Chiropractic to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function. I have had an opportunity to discuss with the doctor of chiropractic and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if l terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor.
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