Patient Intake Form
Basic patient information
  • / /
  • - -
  • - -
  • Problem Description

    Please tell us as much as possible so we can help you as best as we can.
  • Privacy Notice

    As required by the Privacy Regulations, I hereby acknowledge that I have reviewed the privacy policies of William M. Thomas, D.C. at http://www.DrTChiro.com/PrivacyPolicy.html., "NOTICE OF PRIVACY PRACTICES," revision date 04/14/03.

    As required by the Privacy Regulations, William M. Thomas, D.C., or the front desk person from William M. Thomas, D.C, Inc. has informed of the "NOTICE OF PRIVACY PRACTICES" to my satisfaction.

    As required by the Privacy Regulations, I am aware that William M. Thomas, D.C., Inc. has included a provision that it reserves the right to change the terms of its notice and to make the new notice provisions for all protected health information that it maintains.

    I understand that this office is not required to honor any changes to the "Notice of Privacy Practices." not made by our office.

    **NOTE: The policy basically says that we will not give out your Private Health Information (PHI) unless we have your permission or are compelled to legally. Essentially doctor/patient privilege. Details are at http://www.DrTChiro.com/PrivacyPolicy.html
  • Informed Concent

    To the patient: Please read this entire section prior to agreeing to it. It is important that you understand the information contained in this document. Please ask questions before you sign if there is anything that is unclear.

    THE NATURE OF THE CHIROPRACTIC ADJUSTMENT

    The primary treatment I use as a Doctor of Chiropractic Is Spinal Adjusting, also known as, spinal manipulative therapy. I will use that procedure to treat you. I may use: 1. My hands or 2. A Mechanical Instrument upon your body in such a way as to move your joints (please advise if you have a preference). That may or may not cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

    Analysis / Examination / Treatment

    As a part of the analysis, examination, and treatment, you are consenting to the following procedures:
    Please click on each procedure you are consenting to. Your doctor may or may not utilize all of these procedures, if you have questions regarding these treatments, please feel free to ask.

    The material risks inherent in chiropractic adjustment.

    1. Some patients will feel some stiffness and soreness following treatment and may last from hours to the first few days of treatment. The soreness is typically described as “workout soreness”. You may or may not feel soreness. Please inform Dr. Thomas about your response to treatment so we can make any necessary changes to your treatment.

    2. As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. Examination and history decreases the possibility of complications, so please inform the doctor of any relevant information. These complications, although screened for, and are rare, include, but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns when using heat therapy.

    3. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. One study notes that there is no difference between a visit to a MD or a chiropractor as visits to a chiropractor for headaches or neck pain to both specialties could be a stroke in progress. We will make every reasonable effort during the examination to screen for contraindications to treatment; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform the doctor.

    The probability of those risks occurring are exceptionally rare:
    Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

    To put this risk in perspective: Chances of being killed next year from any form of transportation accident: 87 to 1. Chances of being murdered: 19,000 to 1. Chances of being killed by a lightning strike: 2,290,000 to 1. Chances of lightning striking you: 587,000 to 1. Chances of drowning in the bathtub: 693,000 to 1. Chances of being killed in an airplane accident: 355,318 to 1. Chances of being executed for capital punishment: 1 in 3,221,700. Source: Casinomaze.com, lightningsafety.com

    The availability and nature of other treatment options.
    Other treatment options for your condition may include:
    • Self-administered, over-the-counter analgesics and rest
    • Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers
    • Hospitalization
    • Surgery

    If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

    The risks and dangers attendant to remaining untreated.
    Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

    DO NOT CHECK THIS BOX UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
  • Informed Consent Section

    Please read carefully and check all that apply
Powered byEMF Form Builder
Report Abuse