!The Spinal Tuning Chiropractic Center

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PATIENT APPLICATION FORM !WELCOME TO OUR CLINIC. We specialize in assisting our patients to achieve their highest level of health through our spinal maintenance. Our approach is very unique and advanced from other rehabilitative programs. This allows our patients to achieve far superior results compared to most other systems.

!Please fill out the following information thoroughly so the doctor can let you know if you are a case we can accept. Please feel free to ask any questions if you need assistance. We look forward to serving you.

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Patient Signature:

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Today’s Date:

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File #: (office use only)

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Thank you for choosing The Spinal Tuning Chiropractic Center !

Welcome to The Spinal Tuning Chiropractic Center

When a person seeks the services of a chiropractor, it is essential that they fully understand the objectives of that particular chiropractor.

We have one goal at The Spinal Tuning Chiropractic Center that is to restore and maintain the integrity of the spinal cord and its nerve roots. These vital nerve pathways are located in and protected by the bones of the spine. Misalignments of the vertebrae (bones of the spine), which interfere with the function of these

nerve pathways, are called vertebral subluxations. Subluxations are caused by many of the things you do everyday and keep your whole body from functioning properly. It is our absolute conviction that the body is always better off without this interference.

Consequently, the objective of this Chiropractic Center is to provide a chiropractic adjustment to correct subluxation thereby restoring normal nerve function. It is not the objective or intention of Dr. Rohlfsen to fix, treat or attempt to cure any physical, mental or emotional ailments or to give advice about any ailments. With a proper nerve supply your whole body is better able to reach its full potential and to express more life.

The information we receive from you is important. We ask only that which is necessary for your care here at The Spinal Tuning Chiropractic Center. Please fill out the forms completely and to the best of your ability. If you have any questions or if there is any information you feel we should know, please mention it to the chiropractor.

I (we), ___________________________________, have read the above,

understand it fully, and choose to receive chiropractic for ourselves and our

family members (listed below) on this basis.

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Date: __________________

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Thank you for choosing The Spinal Tuning Chiropractic Center !

ABOUT YOU

NAME: _________________________________ Cell/Home Phone:____________________(Please Print) Work Phone: ________________ E-mail: ___________________________________________________

Complete Address: ____________________________________________________________________

Apt. #__________ City/State:________________ ________Zip Code:___________________

Date of Birth:__________ Sex: M __ F __ Occupation:______________________________________

Name of Spouse:__________________________ Number of Children:______________________

Children's Names & Ages: _________________________________________________________________________________________________________________________________________________

Hobbies & Interest (what do you do for fun?) _________________________________________________________________________________

Have you been to a chiropractor before? Yes ___No ___

If yes, who and when: ___________________________________________________________________

Have you been seen by a medical doctor for any reason in the last year? Yes ___ No___ If yes, explain:

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Do you have a family physician? Yes___ No____

What brings you to the office today? ______________________________________________________

How does what’s bringing you into the office affect your LIFE?

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If you have no specific problem but are here to have your spine checked for vertebral subluxation, check here ___ .

Have you had any surgeries, falls, accidents or injuries? Yes ___ No ___ If yes, please list what and when.

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!Thank you for choosing The Spinal Tuning Chiropractic Center !

!Acknowledgement of Receipt of Notice of Privacy Practices !

!!I understand and have been provided with the opportunity to review a Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges: !

❑ The right to review the notice prior to signing this consent, ❑ The right to object to the use of my health information for directory purposes, and ❑ The right to request restrictions as to how my health information may be used or disclosed to carry

out treatment, payment or health care operations. !Appointment Reminders and Health Care Information Authorization !Your chiropractor and members of the practice staff may need to use your name, address, phone number, and your clinical records to contact you

with appointment reminders, information about treatment alternatives, or other health related information that may be of interest to your. If this

contact is made by phone and you are not at home, a message will be left on our answering machine. By signing this form, you are giving us

authorization to contact you with these reminders and information.

!Patient Signature: Date:

!If not signed by the patient, please indicate relationship.

❑ Parent or guardian of minor patient ❑ Guardian or conservator of an incompetent patient ❑ Beneficiary or personal representative of deceased patient !

Name of Patient: __________________________________________________

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Thank you for choosing The Spinal Tuning Chiropractic Center !

Thank you for choosing The Spinal Tuning Chiropractic Center !