Pediatric History Form | Align the Spine Chiropractic

Today's Date(Required)

Child's Name(Required)

First Last

Birthdate(Required)

Age(Required)

Sex(Required)

Male

Female

Birth Height(Required)

Birth Weight(Required)

Current Height(Required)

Current Weight(Required)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Mother's Name(Required)

First Last

Mother's Birthdate(Required)

Mother's Home Phone

Mother's Work Phone

Mother's Mobile Phone(Required)

Mother's Email(Required)

Father's Name(Required)

First Last

Father's Birthdate(Required)

Father's Home Phone

Father's Work Phone

Father's Mobile Phone(Required)

Father's Email(Required)

Pediatrician / Family MD Name(Required)

First Last

Address(Required)

City State

Last Visit Date(Required)

Reason for Visit(Required)

Who is responsible for this bill?(Required)

AUTHORIZATION TO CONSENT TO TREATMENT

Dear Parent(s):

State law requires that you consent to most medical treatments for your minor child. If an adult other than your child’s parent or legal guardian accompanies him/her to office visits, we will be unable to provide treatment without your written authorization, except in emergency situations.

To authorize an adult other than your child’s parent or legal guardian to consent to medical treatment for your child, please complete the sections below. By completing this authorization, you consent to the sharing of your child’s protected health information with this individual as outlined in our Notice of Privacy Practices.

Name of Parent or Legal Guardian(Required)

First Last

Authorization - I authorize the following individual(s),

Name

First Last

Relationship to child

Name

First Last

Relationship to child

to consent to medical treatment for my minor child/children listed below:

Name

First Last

Date of birth

Name

First Last

Date of birth

Name

First Last

Date of birth

Name

First Last

Date of birth

LIMITATIONS -

Identify any limitation on the kinds of medical services for which this authorization is given. If none are specified, no limitations will be applied.

Identify any limitations on the time frame for which this authorization is given. If none are specified, no limitations will be applied.

PARENTAL CONTACT INFORMATION - If the nature of the medical care is not routine, please try to contact me (us) regarding the health care of my (our) children at the following telephone number(s). If you are unable for any reason to contact me (us), you may rely on the proxy decision maker for consent.

Parent’s Name

First Last

Daytime Phone

Evening Phone

Cell Phone

Parent’s Name

First Last

Daytime Phone

Evening Phone

Cell Phone

Signature of Parent or Legal Guardian(Required)

Date(Required)

Doctor's Signature & Date Signed

Office Use Only

Health Objectives & Clinic Policies

1.) Education - To take control of your health: In order for you to be able to achieve your health goals, our office educates our patients. We also use an online platform, called MoveNow University, to provide a variety of resources and videos that cover health topics and functional exercises to supply the tools you need to achieve those health goals and to transform your life.

2.) Scheduling and appointments: Our most successful patients are the ones who schedule out, and stick with it.

In order for you to reserve times that work best for your schedule, we ask you to schedule out as far in advance as possible (entire 3-4 months is preferred).
It is important to remember, that the times that you schedule are times that we are reserving for you, and turning other patients away.
Should you have to change an appointment time, please call us with as much advanced notice as possible. Cancellations made in less than an hour of the scheduled appointment time will result in a cancellation fee of $50.00 per missed appointment, this includes no call no show appointments.
If you MUST cancel an appointment, please be prepared to reschedule at that time of cancellation. We ask that you make up this appointment.
If you may be running late to an appointment, please call our office so we can ensure your appointment is still safe. Please understand if we are still able to accommodate your appointment that their might be some extra waiting or all services might not be rendered.
If you have any concerns about your frequency or care, please let the front office know and we will help resolve any issues.

3.) Our Mission is to help our patients to achieve a better quality of life: Please help us spread the word by inviting your friends, family and co-workers with you to an appointment so they can see what we do. This is the best way to help those you know who are suffering! I consent to receive email updates about clinic promotions, patient education and all other clinic communications. v

Email(Required)

Signature(Required)

Date(Required)

Financial Policy

Notice:

In an effort to maintain compliance with various state and federal regulations, managed care and preferred provider agreements, as well as billing and coding guidelines, we have adopted the following financial policies:

Our clinic has established a single fee schedule that applies to all patients for each service provided.

You may be entitled to a network or contractual discount under the following circumstances:

▪ Patients who meet state and or federal poverty guidelines or other special circumstances outlined in our “Hardship Policy” may be offered a discount for a period of time as determined by the clinic. Verification will be required.

▪ Patients who meet the terms outlined in our “Professional Courtesy Policy” may be offered a discount for services.

▪ Patients who are a part of an Employee Corporate Program will be eligible for discounts as agreed upon and outlined in writing between both Align the Spine Chiropractic, LLC and the company of the employee. These discounts will be specified to individuals by their place of employment. As part of our compliance plan, as of 12/1/21 our office will be unable to extend any type of discounts other than those listed above.

Acknowledged By: Name(Required)

First Last

Signature(Required)

Date(Required)

Align the Spine

Pediatric History Forms

CHILD’S CURRENT PROBLEM

Check all that apply

AUTHORIZATION TO CONSENT TO TREATMENT

Health Objectives & Clinic Policies

Financial Policy

Align the Spine Pediatric History Forms

CHILD’S CURRENT PROBLEM

Check all that apply

AUTHORIZATION TO CONSENT TO TREATMENT

Health Objectives & Clinic Policies

Financial Policy

Align the Spine

Pediatric History Forms