ࡱ> TVSq` 0bjbjqPqP cP::($<*<*<*<*X*\0*****+++///////$1ho3/:-++:-:-/**/D/D/D/:-**d/8D/:-/D/D/D/** @c<*..D/d//00D/3D.3D/3D/ +L+6D/!,,M,+++//D/+++0:-:-:-:-$%<*<* Zanetti Chiropractic, Inc Family Wellness Center Dr. Dina Zanetti DeBolt 4817 NE 2nd Loop Ocala, FL 34471 (352) 624-2337 Fax (352) 624-3501 Referred By: __________________ Dear New Patient: Welcome to our office. In order for us to provide you with the best chiropractic care, please take the time to fill out the following information completely: Patient information: _________________________________________________ First Name Middle Last Name _____________________________________________________________ Mailing Address _____________________________________________________________ City State Zip Code (______)_______-__________ (______)_______-__________ Home Phone Work Phone _______-_______-________ _______/________/_______ Social Security No. Birth Date Marital Status: __Single __Married __Divorced __Widowed Occupation: ___________________________________________ Employers Name and Address: _______________________________________________________ _______________________________________________________ E-Mail Address: _______________________________________ Method of Payment for Todays Visit __ Check __ Cash __ Credit Card Insurance Information: Company Name: _______________________________________ Mailing Address: _______________________________________ ________________________________________________________ Phone #: ______________________________________________ Insureds ID#: _________________________________________ How much is your deductible? $_________________________ Have you met your deductible this year? __ Yes __ No Our policy requires payment in full for all services rendered at the time of the visit unless other arrangements have been made with the office manager. If your account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account. For Women Are you pregnant? __ Yes __ No What was the date of your last period? __________________ Pain and Symptoms Describe your pain and its location: ____________________ ________________________________________________________ ________________________________________________________ What was the cause of your present symptoms? ________________________________________________________ How long have you had this condition? _________________ Have you had these symptoms before? __ Yes __ No If yes, please explain: __________________________________ ________________________________________________________ Does your pain radiate to other areas? __ Yes __ No If yes, where? __________________________________________ What aggravates your condition? _______________________ ________________________________________________________ What relieves your condition? __________________________ ________________________________________________________ Have you seen any other doctors for this condition? __ Yes __ No If yes, please explain: ____________________ ________________________________________________________ Have you previously received chiropractic care? __Yes __No If yes, how long since your last visit? ______________ Are you interested in a maintenance program? __Yes __No Medical History Do you have any health problems? __ Yes __ No __ Heart __ Lungs __ Kidneys __ Thyroid __ Other If yes, please explain: __________________________________ ________________________________________________________ ________________________________________________________ ________________________________________________________ Have you had any surgeries? Please explain _____________ ________________________________________________________ ________________________________________________________ Have you had any broken bones or fractures? __Yes __No If yes, please explain: __________________________________ ________________________________________________________ ________________________________________________________ Have you had any accidents or traumas? __Yes __No If yes, please explain with dates: _______________________ ________________________________________________________ ________________________________________________________ I authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my medical status. Signature: ____________________________________________ Zanetti Chiropractic, Inc Family Wellness Center Dr. Dina Zanetti DeBolt 4817 NE 2nd Loop Ocala, FL 34471 (352) 624-2337 Fax (352) 624-3501 TERMS OF ACCEPTANCE When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working for the same objective. Chiropractic has only one goal. It is important that each patient understands both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: The adjustment is the specific application of force to facilitate the bodys correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. Health: The 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 bodys innate ability to express its maximum health potential. We do not offer, diagnose, or treat any disease. We only offer to diagnose either vertebral subluxations or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of another health care provider. Regardless of what the 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 major interference to the expression of the bodys innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. However, we may use other procedures to help your body hold the adjustments. I, __________________________________have read and fully understand the above statements. (print name) All questions regarding the doctors objective pertaining to my care in this office have been answered to my complete satisfaction. Therefore, I accept chiropractic care on this basis. _______________________________ ____________________ (signature) (date) Consent to evaluate and adjust a minor child I, _______________________________being the parent or legal guardian of ______________________________ have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic are. Pregnancy Release This is to certify that to the best of my knowledge I am not pregnant and the above doctor and his/her associates have my permission to perform an x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child. Date of last menstrual cycle. _____________ _____________________________________ ________________________ (signature) (date) Zanetti Chiropractic, Inc Family Wellness Center Dr. Dina Zanetti DeBolt 4817 NE 2nd Loop Ocala, FL 34471 (352) 624-2337 Fax (352) 624-3501 Receipt of Notice of Privacy Practices Written Aknowledgement Form I, ________________________________ have read a copy of Zanetti Chiropractic, Incs (Patient name) Notice of Patient Privacy Practices. ________________________________ ______________ (Signature of Patient of (Date) Parent or legal Guardian) Zanetti Chiropractic, Inc Family Wellness Center Dr. Dina Zanetti DeBolt 4817 NE 2nd Loop Ocala, FL 34471 (352) 624-2337 Fax (352) 624-3501 Patient Name: ___________________________________________________ Assignment of Insurance Benefits: I hereby authorize payment to be made directly to ZANETTI CHIROPRACTIC, INC. of all benefits which may be due and payable under insurance coverage for the above named patient. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments. I further acknowledge that this assignment of benefits does not in any way relieve me of liability and that I will remain financially responsible to ZANETTI CHIROPRACTIC, INC. Furthermore, I hereby IRREVOCABLY ASSIGN to ZANETTI CHIROPRACTIC, INC. the rights and benefits under any policy of insurance, indemnity agreement, or any other collateral source as defined in Florida Statutes for any service and/or charges provided by ZANETTI CHIROPRACTIC, INC. Authorization To Release Medical Record Information: ZANETTI CHIROPRACTIC, INC., is hereby authorized to disclose all or any part of the medical records on the above named patient to such insurance companies, organizations, or agencies as may be responsible for payment of services rendered by ZANETTI CHIROPRACTIC, INC. This authorization is given with full knowledge that such disclosure may contain information of a confidential nature and may result in a denial of insurance coverage for services rendered by said ZANETTI CHIROPRACTIC, INC. The undersigned certifies that He / She has read and understands each of the above paragraphs and is the patient or responsible party with the power to execute this document and accept these terms. 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