PEDIATRIC PATIENT INTRODUCTION CARD

 
 
  Date : - 
Child's Name:
Age:
Date of Birth:
Street Address:
City, ST, Zip:
Parent's Names:
Phone:
Email:
Whom may we think for referring you to our office?
Name of Person Responsible for the Account:
Relationship to Patient: 
Preferred Phone # :
Address (If different than above) :
Insurance Company : 
Name of Insured :
Relationship to Patient : 
Date of Birth :
Present Health Challenge(s)
For what health challenge(s) is your child here for? When did it begin?
Has your child seen other health care practitioners for this? What did they recommend?
What was the outcome of prior treatment / recommendations?
Is this dysfunction getting progressively worse?                                      
 Health History :-
Symptoms: Please check any current or past problems your child has on the list below:
 
   
Ethnicity :                                 :  
Preferred Language :
Race :
 :  
Name of Pediatrician :
Date of Last Visit :
Current Medications & Vitamins: 
Past Trauma (falls, sports injuries, accidents, etc.)
Past Surgeries:
 Prenatal History :-
 Location of Birth:
 Home
Birthing Center
Hospital
Complications during pregnancy : 

               

List: 
Medications during pregnancy/delivery: 
Cigarette/ Alcohol use during pregnancy:
              
Birth intervention:   
Forceps 
Vacuum 
Caesarian 
Complications during delivery: 

              

List : 
Birth Weight
Birth Length
   
 Feeding History :-
Breast Fed:                                  How long?    
Formula Fed:                              How long?    
 Type: 
Introduced to cereal at  months.
Solids at  months.
Cow's milk at   months.
Food / juice allergies or intolerances  

             
   
 Developmental History 
Sleep (Hrs per night) 
Problems sleeping
   
 Medical / Vaccination History 
 Has your child ever had an adverse reaction to a prescription or over-the-counter medication?
                
If yes please Explain:
Has your child been vaccinated?
                
Adverse reactions to any  Vaccine? 
 Childhood Disease
         
                 
                 
  
                
                   

 Consent For Treatment of Minor

 
I hereby certify the information I have provided is correct and accurate, to the best of my knowledge. 
I,  , as the parent/guardian of this child,  hereby grant permission for my child to receive examination and chiropractic treatment as deemed necessary.

 



 
Signature of Patient or Guardian :    Date :  


 




Runnels Chiropractic, L.L.C.


Authorization and Release
 

I authorize payment of insurance benefits directly to Dr. Steven K. Runnels or Runnels Chiropractic, LLC. I authorize Runnels Chiropractic, LLC to release any information pertinent to my case to any insurance company, adjusters, and / or attorney involved in the case, I hereby release Runnels Chiropractic, LLC of any consequence thereof. I agree to be financially responsible for all charges incurred at Runnels Chiropractic, LLC including my insurance deductible, co-payment, and any other services rejected by my insurance company. Any account unpaid after 30 days of the date of service shall bear interest at the rate of 16% per month. Should it become necessary to resort to collections, the patient shall be responsible for all costs of collections including a reasonable attorney’s fee.


 
 Insurance :
                     
 Company :  
 Patient’s Signature :  
 Date :  
 Guardian’s Signature :  
 Date :  
Clinical Summary Report (CCR)
 
I understand that a clinical summary report is created after each visit for the purpose of EHR and is available for my review. At this time, I am asking Runnels Chiropractic to save these electronically for me and not print them out after each visit. I understand that, upon request, these reports are available to be printed or emailed to me for review.
 
 Patient’s Signature :   Date : 
 

Runnels Chiropractic

Acknowledgement of Receipt of 
Notice of Privacy Practices

This form will be retained in your medical record.

NOTICE TO PATIENT

We are required to provide you with a copy of our Notice of Privacy Practices, Which state how we may use and/or discolse your information. Please sign this form to acknowledge receipt of the Notice.
 
Patient Name: 
Date of Birth: 

I acknowledge that I have received and had the opportunity to review the Notice of Privacy Practices on the date below on behalf of Runnels Chiropractic.

I understand that the Notice describes the uses and disclosures of my protected health information by Runnels Chiropractic and informs me of my rights with respect to my protected health information.
 
Patient's Signature or that of Legal Representative 
Printed Name of Patient or that of Legal Representative 
 
Today's Date
 If Legal Representative, Indicate Relationship