• RENEW NEUROPATHY RELIEF PROGRAM

    - New Patient Application For Care - Our mission is to empower individuals to regain control of their health and lives. Please fill out the application entirely.

  • Patient Demographics

  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Review of Symptoms

  • Please check all that apply*

  • History of Complaint

  • In order of importance, list the health problems you are most interested in getting corrected:*
    Rows
  • List approximately how long you have noticed these problems:*
    Rows
  • List the things you have used for these problems:*
  • If YES when?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Have your symptoms:*
  • How would you describe what your primary complaint feels like?*
  • Is this condition interfering with any of the following?*

  • Social History

  • Do you use or do you have history of using tobacco?*
  • Do you drink alcohol?*
  • Do you exercise regulary?*

  • Current Pain Level

  •

  • Past Health History

  • Have you suffered with any of this or a similar problem in the past?*
  • When was the last episode?
     - -
    2 digit month, 2 digit day, 4 digit year
  • Other forms of treatment tried?*
  • What were the results?
  • Please identify all past and any current conditions:*
    Rows
  • Are you currently taking any medication?*
  • Do you have any medication allergies?*
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  • Family History

  • Does anyone in your family suffer with the same condition(s)*
  • If Yes, Whom?*
  • Check the conditions that apply to you or to any members of your immediate relatives:*

  • Patient Quality of Life Survey

    Please take several minutes to answer these questions thoughtfully so we can help you get better. (PLEASE CHOOSE AS MANY THAT APPLY)
  • 1. How have you taken care of your health in the past?*
  • 2. How did the previous method(s) work out for you?*
  • 3. How have others been affected by your health concern?*
  • 4. What are you afraid this might be (or beginning) to affect (or will affect)?*
  • 5. Are there health conditions you are afraid this might turn into?*

  • X-Rays/Imaging Studies

  • As your healthcare provider, we are legally responsible for your health records. We must maintain a record of your x-rays in our files.

    At your request, we will provide you with a copy of your x-rays in our files.

    A complimentary copy on a CD will be provided.  Additional copies will be charged a fee of $25 which must be paid in advance.

    Digital x-rays on CD will be available with 72 hours of prepayment on any regular practice hours day. Please note: X-rays are utilized in this office to help locate and analyze vertebral subluxations.  These x-rays are not used to investigate for medical pathology. The doctors of Abundant Health Physical Medicine do not diagnose or treat medical conditions; however if any abnormalities are found, we will bring it to your attention so that you can seek proper medical advice.

    By signing below you are agreeing to the above terms and condtions.

  • FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation. The first day of my last menstrual cycle was on:
     - -
    2 digit month, 2 digit day, 4 digit year

  • By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic x-ray examination the doctor has deemed necessary in my case.

  • Informed Consent

  • Abundant Health Physical Medicine - Informed Consent: REGARDING: Medical Services, Chiropractic Adjustments, Modalities, Functional Medicine, Regenerative Medicine, Extracorporeal Shockwave Therapy, Hyperbaric Oxygen Therapy, Aesthetic Procedures and Therapeutic Procedures: A patient coming to the doctor gives him/her permission and authority to care for them in accordance with appropriate test, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities or pathologies may render the patient susceptible for injury. The doctor, of course, will not provide specific healthcare, if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn through health care procedures from whatever he/she is suffering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the physician. I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often minimal, complications such as sprain/strain injuries, irritation of a disc condition, dislocations of joints, and although very rare, fractures, and possible stroke (estimated to be related in one in one million to one in two million cervical adjustments), have been associated with chiropractic adjustments. Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Abundant Health Physical Medicine have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. I clearly understand and agree that all services rendered to me are charged directly to me and that I am responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable. Any equipment purchased may not be returned for refund. I authorize Abundant Health Physical Medicine to release my personal medical information to me. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care. I have reviewed and accepted informed consent.

  • HIPAA Personal Health Information Release

  • I, * herby authorize Abundant Health Physical Medicine to discuss with and/or release information to the following people concerning my appointments, insurance, billing, and health treatment rendered.

  • Restrictions*
  • Messages: (Please Call)*
  • If unable to reach me:*

  • I understand I may terminate this consent at any time by giving written notice to Abundant Health Physical Medicine. Any changes to this form will require a new consent to be completed, signed and dated.

  • Notice of Privacy Practices

    THIS NOTICE DESCRIBES HOW YOUR HEALTH INFORMATION MAY BE USED AND DISCLOSED AND HOW TO ACCESS THIS INFORMATION. Please Review Carefully

  • Acknowledgement of Receipt of Notice of Privacy Practices

  • I acknowledge that I have reviewed the Notice of Privacy Practices of Abundant Health Physical Medicine.

  • (PLEASE INITIAL ONE OF THE FOLLOWING OPTIONS AND SIGN BELOW.)*
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