What is your full name? * As it appears on your ID, insurance card or medical record
What is your date of birth? *
What is your email address? * We'll keep you up to date with office news and announcements
What is your street address? *
What is your city and state? *
What is your postal or zip code? *
What is your phone number? * Enter the best available phone number to reach you.
Who were you referred by?
Will you be a medical insurance patient? YesNo
Upload a picture of the FRONT of your insurance card:
Upload a picture of the BACK of your insurance card:
What is the name of the primary insured?
Is the name of the primary insured the same as the patient? YesNo
Name of Insured:
Insured date of birth:
What is the name of the patient?
What is the name of your insurance company?
Please enter insurance customer service phone number
What is your insurance member ID number?
What is your group number?
Were you in an auto accident? YesNo
What was the date of your vehicle accident? Format Example: Month/Day/Year
What is the name of your auto insurance?
What is the phone number of your auto insurance?
What is the name of the Auto Insurance contact person?
Insurance: What is the claim or policy number?
*Please read the Auto Insurance legal notice and accept to continue.
I understand and agree that health/auto insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Have you ever been treated for any conditions in the last year? YesNo
Please describe the conditions you were treated for...
What is the date of your last physical exam? Format Example: Month/Day/Year
What is the date of your last blood work? Format Example: Month/Day/Year
Are you male or female?MaleFemale
Is there a chance that you may be pregnant? YesNo
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 if needed. I am aware that X-ray, CT or other diagnostic studies can be hazardous to an unborn child.
Have you had X-rays taken? YesNo
Where were the X-rays taken & approximate date?
Are you currently taking medications? YesNo
What medications are you currently taking and for what conditions? Please list dosage and amounts, etc. :
What vitamins, herbs or nutritional supplements do you currently take? Please list for what condition, dosage and frequency
Have you ever broken any bones? YesNo
Briefly explain:
Have you ever been hospitalized? YesNo
Have you ever been in an auto accident? YesNo
Have you ever been struck unconscious? YesNo
Have you ever had surgery? YesNo
How often do you drink alcohol? 01234Please be honest. Your answers are secure.
How often do you intake caffeine? 01234Please be honest. Your answers are secure.
How often do you smoke or vape tobacco? 01234Please be honest. Your answers are secure.
How often do you use drugs (prescribed or recreational)? 01234Please be honest. Your answers are secure.
How often do you exercise? 01234Please be honest. Your answers are secure.
How many hours do you normally sleep? 01234Please be honest. Your answers are secure.
How much water do you drink daily? 01234Please be honest. Your answers are secure.
How often do you eat sugary/sweet food & snacks? 01234Please be honest. Your answers are secure.
What is the nature of your injury?
When was the date your symptoms appeared? Format Example: Month/Day/Year
Have you had the same injury before? YesNo
Please name any other practitioners you've seen for your condition or injury.
Have you ever been under Acupuncture or Chiropractic care? AcupunctureChiropractic
Do you currently or have you suffered from any of the following: AllergiesAnemiaArthritisAsthma or BronchitisBack PainBreast LumpBone Density LossBruise EasilyCancerConstipationDepressionDiabetesDigestion ProblemsDizzinessTinnitus/Ears RingUnusual FatigueFrequent UrinationHeadachesHigh Blood PressureHot FlashesIrregular Heart BeatKidney Infection/StonesLoss of BalanceMid Back PainNeck Pain or StiffnessNosebleedsPacemakerPoor PostureProstate TroubleSciaticaSleep Problems/InsomniaSpinal CurvaturesStroke/Heart conditionSwelling of AnklesThyroid ConditionUlcers
Do you experience pain or symptoms every day? YesNo
Do your symptoms interfere with daily life? Please explain briefly:
Are your symptoms worse during certain times of the day? YesNo
Briefly explain…
Do changes in weather affect your symptoms? YesNo
Do you wear foot orthopedics? YesNo
What activities aggravate your symptoms?
What area is bothering you? Please select your body's region. HeadNeckShoulder (Right)Shoulder (Left)Elbow (Right)Elbow (Left)Wrist (Right)Wrist (Left)Hand (Right)Hand (Left)Hip (Right)Hip (Left)Knee (Right)Knee (Left)Ankle (Right)Ankle (Left)Foot (Right)Foot (Left)Leg (Right)Leg (Left)Back (Upper)Back (Mid)Back (Lower)
What type of pain is this causing you? PainLoss of Use/MovementAltered Sensation
I do hereby authorize the Doctors & Licensed Acupuncturists of Premiere Healthcare to administer such care that is necessary for my particular condition(s). This care may include, but are not limited to, review of medical history, examination, acupuncture, herbal medicine, spinal or extremity adjustments, soft tissue or manual therapies (myofascial release, cupping, gua-sha, tui-na, qigong), physiotherapy modalities (ice, heat, electric stimulation), nutritional and lifestyle counseling and/or laser therapy that is advisable, and necessary for my health condition(s).
I understand, that if recommended, herbal medicine needs to be prepared and teas need to be consumed according to instructions provided orally and in writing. The herbs may have unpleasant smell or taste. I will immediately notify my practitioner or clinical staff member of any unanticipated or unpleasant effects associated with the treatment or consumption of herbs.
Furthermore, I authorize and agree to allow the Doctors & Acupuncturists of Premiere Healthcare to work with my health condition(s) through the use of acupuncture needling, spinal adjustments, various soft tissue or manual therapies, physiotherapy modalities, nutritional supplements, herbs and homeopathic remedies, rehabilitative exercises and/or laser therapy for the sole purpose of postural and structural restoration to allow for normal biomechanical and neurological function. I have had an opportunity to discuss with one of the Doctors or Acupuncturists of Premiere Healthcare and/or with other office or clinic personnel regarding the nature and purpose of recommended treatment and other procedures related to my health care.
I understand that I am responsible for all fees incurred for the services/products/durable medical equipment provided and agree to ensure full payment of all charges. I further understand that a fee for services or products rendered will be charged and that I am responsible for this fee whether results are obtained or not.
I understand and am informed that as in the practice of medicine and dentistry, in the practice of Acupuncture, Chiropractic & Oriental Medicine there are risks to treatment including, but not limited to fractures, disc injuries, burns, stroke, dislocations, sprains, headaches, temporary increased soreness or pain, nausea or lightheadedness and emotional release. I do not expect the Doctor or Acupuncturist to be able to anticipate and explain all risks and complications of a given procedure on any visit, and I wish to rely on the Doctor or Acupuncturist to exercise judgment during the procedure which they feel at the time, based upon the facts then known, is in my best interest. The Doctor or Acupuncturist will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the conditions treated at this clinic.
I understand there are other forms of treatment, including drugs and surgery, which could be treatment options for my condition(s), but at this time, I choose acupuncture, chiropractic, nutrition and/or oriental medicine. I understand that acupuncture or oriental medicine is not a replacement for diagnostic medical procedures and that an Acupuncturist does not diagnose according to standard medical practice. I further acknowledge that my practitioner is not a medical doctor, Doctor of Osteopathy or Doctor of Physical Therapy and does not claim to practice within the scope thereof.
I have read or have had read to me, the above consent. I have been told of the risks also had the opportunity to ask questions about this consent, and by submitting this form I agree to the above-above named procedures. I intend this consent form to cover the entire course of care for my present condition and for all future conditions(s) for which I seek treatment.
Your appointments and well-being are very important to us. We understand that sometimes unexpected delays can occur, making schedule adjustments necessary. If you need to cancel or change your appointment, we require a 48 Hour Notice, prior to your scheduled appointment so that we may have time to offer the opening to another patient.
By scheduling appointments, you agree to the terms of our no-show/late cancel/ late reschedule policy. We reserve the right to charge a Cancellation Fee of $50 for all appointments cancellations or late rescheduling (less than 48 hours prior). We cannot bill your insurance for no shows.
Cancellation fees will be charged to your card on file the day of your scheduled appointment. If no card on file, payment of cancellation fee will be required prior to securing your next appointment. Repeated violations of our cancellation policy will result in the patient being required to pay the full price of any scheduled services upfront or upon any cancellation with less than 48-hour notice.
I have read and understand the Premiere Healthcare appointment No-Show/Late Cancellation Policy and agree to the terms noted herein.
By submitting this form you acknowledge and agree to the above terms and conditions.
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