Dear Patient: This information is considered confidential. Your answers will help us determine if chiropractic can help you. If we do not sincerely believe your condition will respond satisfactorily, we will not accept your case. In order for us to understand your condition properly, please be as neat and accurate as possible while completing this form. Thank You!
Marital Date of Number of
Name___________________________ Sex____ Status ______ Birth _____________Age ____ Children ____
SSN_____________ Home Phone _________________ Cell Phone _________________ Referred By_____________
Address___________________________________________ City____________________ State ______ Zip________
Do you smoke? ____Yes ____No Consume Alcohol ____Yes ____No Are you: Right Handed or Left Handed ?
Email address: ______________________________________________ Today’s Date: _________________
Date of accident: ___________________ Time of accident: _________AM _________PM
Were you the: ___Driver; ___Front Passenger; ___Lt. Rear Passenger; ___ Rt. Rear Passenger
Were you wearing a seatbelt: ___Yes ___No
What street were you on at the time of the accident: ____________________________________________________
What city/town were you in at the time of the accident: __________________________________________________
What was the speed of your vehicle at the time of the accident: ___________________________________________
What was the speed of the vehicle that hit you at the time of the accident: ___________________________________
What was the make and model of the vehicle you were in: ________________________________________________
What was the make and mode of the vehicle that hit you: ________________________________________________
Where was your vehicle hit [check one]:
___Front; ___Rear; ___Right front; ___Right Center
___Right rear; ___Left front; ___Left center; ___ Left rear
If your vehicle was stopped, how far was it pushed as a result of the impact: _________________________________
At the point of the impact were you looking: ___ Forward; ___Right; ___Left
Were you [check one]: ___Aware of the impact; ___Surprised by the impact
Did you hit your head on impact: ___No ___Yes; if yes then on what: ______________________________________
Did any other body part hit anything in the vehicle: ___No ___Yes; if yes then please explain: ______________________________________________________________________________________________
Were you unconscious as a result of the injury: ___No ___Yes; if yes how long: ______________________________________________________________________________________________
Were you bleeding as a result of this injury: ___No ___Yes; if yes please describe: ______________________________________________________________________________________________
Please describe the pain you experienced immediately after the accident:
Have you ever had any complaints in the involved area before? ____Yes ____No
If yes, what were the complaints? _________________________________________________________________
Before the injury were you capable of working on an equal basis with others your age? ____Yes ____No
Were you ever involved in a motor vehicle accident prior to this accident? ____Yes____No
If yes, How many?____
What was/were the date(s) of the accident(s)____________________________________________________
Were you injured from the accident? (If yes, explain)______________________________________________
Were you treated for the injuries? (If yes, where were you treated?)_________________________________
How long did you receive treatment?______________Did you have pain after the treatment?_____________
Describe your main area of pain:
If you have headaches circle the appropriate responses (see below for descriptions of ratings):
Front of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4
Side of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4
Back of Head: Grade – 1 2 3 4 Side – Right Left Both Frequency – 1 2 3 4
1 = minimal, the pain is annoying but is forgotten during activities of daily living
2 = slight, the pain is tolerated, but it does interfere with some daily activities
3 = moderate, the pain extensively interferes with activities including sleep, recreation, etc.
4 = marked, the pain prevents most activities, including sleep, recreation, etc
Side: If your pain is in the front or back is it to the right, left or both sides? Grade each headache separately if it occurs in more than one area.
Headache pain frequency:
1 = I have intermittent symptoms occurring up to 25% of my awake time
2 = I experience occasional symptoms between 25-50% of the time
3 = Pain is frequent and occurs between 50-75% of the time
4 = I have constant pain occurring between 75-100% of my awake time
PERSONAL INJURY INSURANCE INFORMATION (REQUIRED)
Your Automobile Insurance Company: Name of Company___________________________________________Phone____________________________
Claim #____________________________Has your insurance company been notified of the accident? Yes or No
Driver Information (If you were not driving and the driver is the owner of the vehicle): Name of driver_______________________________________________Phone___________________________
Driver’s Automobile Insurance Company (Only fill in if you were a passenger and do not have automobile insurance of your own) Name of Company____________________________________________Phone___________________________
Policy #_____________________________Has the insurance company been notified of the accident? Yes or No
Your Health Insurance Information: Name of Company______________________________________________Policy #________________________
Are you covered by Medicare? Yes or No If yes, what is your insurance number?_______________________
Advising Attorney Information: Name of Attorney_____________________________________________Phone___________________________
Assignment of Benefits by a Patient to a Physician: I hereby assign to my physician all benefits for such services to which I am entitled under my Personal Injury Protection and/or Medical Payments coverage, and request my insurance company to pay any such benefits directly to my physician upon submission of any claim.
In order for this office to process your claim efficiently, it is necessary to obtain the following information regarding other health benefits available to you.
Any medical expenses in excess of $2,000 will not be paid under your Auto policy if those expenses will be compensated, paid, or indemnified by an outside insurance carrier. Bills submitted to your Auto insurance carrier over the $2,000 limit must be accompanied by an explanation of benefits from your health carrier or a copy of this Affidavit.
If you have health insurance benefits through Mass Health ONLY, please complete Section One. For all other health insurance benefits, complete section two. If you do not have any health benefits available to you, please complete section 3.
Initial the Correct Box
I hereby certify that I have Mass Health as a healthcare provider with NO other healthcare benefits available to me.
MassHealth ID Number
I hereby certify that I have the following health insurance benefits available to me: Health Insurance Co: _______________________________________________________
Policy Number: ____________________________________________
I hereby certify this I do not have any accident and/or health benefits available to me through my own policy or that of a household member.
Carrier 1: __________________________________________________________
Carrier 2: __________________________________________________________
RE: PATIENT RECORDS, IME REQUEST, PIP Application and DOCTOR’S LIEN I do hereby authorize Waltham Chiropractic to furnish my Attorney/Insurance carrier, with a full report of my case history, examination, diagnosis, treatment, and prognosis in regard to my accident/illness which occurred/began on ____________.
I also authorize and request my Attorney/Insurance company to send any IME report, PIP Application or request for me to attend an IME to Waltham Chiropractic.
I hereby give a lien to said Doctor on any settlement, claim judgment, or verdict as a result of said accident/illness, and authorize and direct you, my Attorney/Insurance carrier, to pay directly to said Doctor such sums as may be due and owing him for service rendered me, and to withhold such sums from such settlement, claim, judgment, or verdict as may be necessary to protect said Doctor adequately.
I understand that I am directly and fully responsible to said Doctor for all Chiropractic bills submitted by him for service rendered me, and that some procedures may not be covered by my health insurance, and that this agreement is made solely for said Doctor’s additional protection and in consideration of his awaiting payment. And I further understand that such payment is not contingent on any settlement, claim, judgment, or verdict by which I may eventually recover said fee.
Dated: ____________________ Signature: ____________________________________
The undersigned, being Attorney of record or authorized representative of insurance carrier for the above patient does hereby acknowledge receipt of the above lien, and does agree to honor the same to protect adequately said above named Doctor.
Dated: _______________________ Authorized signature: _________________________
Autorizo a mi Doctor Quiropractico para proveer cualquier clase de informacion relacionada con mi case, a mi abogado/Compania de Seguros. Authorizo a mi abogado/Compania de seguros para pagar directamente a mi Doctor. Estoy informado de que soy responsable por pagar mes cuentas medicasopracticas. El pago de mis cuentas no esta basado en ningun caso judicial o verdicto.
136 Bacon Street
Waltham, MA 02451
Dr. John Duffy
When a patient seeks chiropractic care and when a chiropractor accepts a patient for such care, it is essential that they both be seeking the same goals. The practice of chiropractic in this office consists of analysis and adjustment of the spine for the purpose of locating and correcting vertebral subluxations. (spinal misalignments causing nerve interference). We also strive to educate and encourage our patients/practice members to become aware of and responsible to their well being.
Our intention is to provide you with the best care we can offer as outlined above. We do not offer care with the intent of “treating” or “curing” diseases or conditions.
Physicians, chiropractors, osteopaths and physiotherapists using manual manipulation are required to advise their patients that there have been rare incidents of injury to the vertebral artery during the course of treatment. There have caused strokes or stroke-like occurrences which are usually of a temporary nature. The chances of this happening are approximately 1 in 3 million treatments. There have also been rare incidents of rib bruising or swelling of aggravation of symptoms. Appropriate tests will be performed on you to minimize your risks.
It is important that you understand that chiropractic care involves a “hands on” approach. During the delivery of a chiropractic adjustment or diagnostic procedure, there may be physical contact made in possibly sensitive areas. By signing below you are acknowledging that you have been informed of and consent to the type of care you will receive and that you have been made aware of any risks inherent in that care. You also acknowledge that you have been made aware of other treatment options. If a change in approach, additional testing, and referrals to other providers or a need to apply care requiring a different touch is required it will be discussed with you prior to it being administered. If at any time you are in any way uncomfortable with any aspect of the care that you are receiving, please do not hesitate to let us know.
Our practice is based on the simple truth that if we satisfy and delight our patients, they will get well faster and be more likely to tell others about their chiropractic experience. Since chiropractic results vary, we can’t guarantee results, but we can promise your satisfaction. Within 3 days of beginning care, if you are not completely happy with your decision to begin chiropractic care in this office, we will happily refund the money you’ve paid us.
I/We understand and consent to care at Waltham Chiropractic for myself/my family, as outlined in this “Informed Consent”.
Signed: ____________________________________ Name (print) ______________________________
136 Bacon St.
Waltham, MA 02451 Cancellation Fees & Agreement The staff at Waltham Chiropractic takes the time to treat all patients as efficiently as possible. In order to do that, we schedule appointments so that patients can be seen and treated in a timely manner. In order to maintain a proper schedule, we must now enforce a cancellation policy to all patients.
If you cancel an appointment less than 24 hours prior to it, or you do not show up for the appointment, you will be charged a $15 fee. This fee is waived if you make up that appointment within a week.
Please note scheduling an appointment is required. If you walk in for an appointment we cannot guarantee you will be seen immediately.
I, _______________________________, understand that I will be charged a $15 fee for any scheduled appointment that I cancel with less than 24 hours notice, or do not show up for.