910-295-1215

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910-295-1215

315 Page Rd, Suite 11

Pinehurst, NC 28374

Home
Office Tour
- Meet The Team
- What Can I Expect
Massage Therapy
Services
Our Practice
Schedule an Appointment
Patient Forms
Automobile Accident / Personal Injury
- Automobile Accident Injury
- Personal Injury
Patient Resources
Contact Us
- Map & Directions
Testimonials
FAQ
Insurance & Payment Options

Welcome To Our Practice

Physical Therapy Personal Injury Intake

Physical Therapy Personal Injury Intake

Let us get started filling out this form.

I understand this is a legal agreement and Intend to sign,
I also Agree to sign this agreement electronically.
Terms of consent

Pinehurst Chiropractic Center

Confidential Patient Intake Information

315 Page RD Suite 11,

Pinehurst, NC 28374
Phone: (910) 295-1215

Fax: (910) 295-1814

Website: www.pinehurstchiro.com

Date:*

Patient's FULL Name*

Called Name

Home Phone:

Cell Phone:*

E-Mail:*

Language:*

Is your Ethnicity Hispanic or Latino*

Please select at least one option

Yes

Race:*

Please select at least one option

American Indian

Alaska Native

Asian

White

Black or African American

Native Hawaiian

Other Pacific Islander

Other

Decline to state

Gender:*

Please select one option

Male

Female

Other

Age:*

Height:*

Weight:*

Social Security #*

Date of Birth*

Mailing Address:*

City:*

State/Province*

Please select one option

Zip Code:*

Marital Status*

Please select at least one option

Married

Single

Widowed

Seperated

Divorced

Number of Children/Ages*

Work Status:

Employed

FT Student

PT Student

Retired

Unemployed

Occupation:

Hours/Week*

Employer:

Business Phone:

Spouse's Name:

Spouse's Employer:

Spouse's Business Phone:

Emergency Contact Name:*

Relationship:*

Emergency Contact Phone Number:*

Emergency Contact Address:*

Emergency Contact City:*

Emergency Contact State:*

Emergency Contact Zip Code:*

Family Physician:*

Family Physician City:*

Family Physician State:*

Family Physician Phone:*

May our office inform your family physician of presenting conditions/s, exam findings, diagnosis, and treatment plans?*

Please select at least one option

Yes

Do you have health insurance? If yes, please present insurance card to Front Desk Staff.*

Please select at least one option

Yes

Previous Chiropractic and/or Physical Therapy Care?

Yes

If yes, for what problem?

How long since your last Chiropractic and or Physical Therapy treatment?

Referred by:

Mark your areas of pain:

Chief Complaint:*

Severity of pain (0 = No Pain 10 = Unbearable)*

Please select at least one option

Are there any other complaints?*

Please select one option

Yes

Complaint #2*

Severity of pain (0 = No Pain 10 = Unbearable)*

Please select at least one option

Is there an additional complaint?*

Please select one option

Yes

Complaint #3*

Severity of pain (0 = No Pain 10 = Unbearable)*

Please select at least one option

Date of Onset:

Was on the Onset

Gradual

Sudden

Since onset, has it gotten:*

Please select at least one option

Worse

Better

What caused the pain?*

Secondary or related complaint(s) if any:

Past Conditions:*

PLEASE ANSWER THE FOLLOWING QUESTIONS TO HELP EXPLAIN YOUR CHIEF COMPLAINT:

Describe the quality of the complaint/pain:*

Please select at least one option

Sharp

Dull/ache

Throbbing

Tingling/numbness/burning

Other

If other, please explain

Does any of the following make the pain worse:*

Please select at least one option

Lifting/bending/pushing/pulling

Cough/sneeze/bowel movement

Driving/riding/sitting

Walking/running/standing

Other

If other, please explain

Does any of the following make the pain better:*

Please select at least one option

Rest/laying down

Sitting

Walking/exercise

Other

If other, please explain

Describe if pain is in a single spot or does it spread out*

Please select at least one option

Single spot

Radiates (ex. down leg/arm)

Other

Please explain radiate or other:

How often are you aware of the pain:*

Please select at least one option

Intermittent (less than 25% of time awake)

Occasional (25-50% of time awkae)

Frequent (50-75% of time awake)

Constant (75-100% of time awake)

Does it interfere with your daily activities:*

Please select at least one option

Minimal (annoyance, no impairment)

Slight (tolerated, some impairment)

Moderate (marked impairment)

Marked (preclude any activity)

Has your current complaint lead to or been associated with any of the following:

Muscle Weakness

Bowel/Bladder Problems

Digestion

Cardiac/Respiratory

Other

Hospital Admission

If other, please explain:

If hospital admission, when so?

Transported?

Yes

Procedures performed:

Do you have any work restrictions (Off duty)?

Yes

Do you have any work restrictions (Light duty)?

Yes

What type of care are you interested in?

Pain relief only

Healing of current condition(s)

Performance enhancement

All three

What is your long term goal from treatment (e.g. play a round of golf without pain)?*

Smoking status:*

Please select at least one option

Current Daily

Current Some

Former Smoker

Never Smoked

Trying to Quit

Do you exercise?*

Please select at least one option

Yes

How many times per week?

Do you use other forms of tobacco?*

Please select at least one option

Yes

What/How much per day?

Do you consume alcohol?*

Please select at least one option

Yes

How many drinks per week?

Do you have a healthy diet?*

Please select at least one option

Yes

If no, explain:

Do you get adequate sleep?*

Please select at least one option

Yes

If no, explain:

Is work stressful to you?*

Please select at least one option

Yes

If yes, explain:

Is family life stressful to you?*

Please select at least one option

Yes

If yes, explain:

Do you use recreational drugs?*

Please select at least one option

Yes

If yes, explain:

In general, would you say your health is:*

Please select one option

Excellent

Very Good

Good

Fair

Poor

Past Health History:

FAMILY HISTORY: Have any of your immediate family members had diabetes, cancer or back pain?*

Please select at least one option

DIABETES

CANCER

BACK PAIN

NONE

List the family members that had Diabetes, Cancer, and/or Back Pain*

Have you ever experienced your present problem before?*

Please select at least one option

Yes

If yes, when?

Was treatment provided?*

Please select at least one option

Yes

If yes, by whom?

What was the out come of the treatment?

Have you EVER had a stroke or issues with blood clotting?*

Please select at least one option

Yes

If yes, when?

Have you recently experienced dizziness, unexplained fatigue, weight loss, or blood loss?*

Please select at least one option

Yes

If yes, explain:

Have you EVER had any major illnesses, injuries, broken bones, hospitalizations, accidents, or surgeries?*

Please select at least one option

Yes

Date:

Injury/Fracture/Illness/Surgery:

Treatment:

Results:

Date:

Injury/Fracture/Illness/Surgery:

Treatment:

Results:

Date:

Injury/Fracture/Illness/Surgery:

Treatment:

Results:

Are you currently taking anti-coagulant or blood thinning medication?*

Please select one option

Yes

Are you presently taking any prescription drugs, over the counter drugs, vitamins, supplements?*

Please select one option

Yes

Have there been any changes to your medication?*

Please select one option

Yes

Do you have any allergies to medications? If yes, please explain*

Please select one option

Yes

Explain Here:

Product/Drug:*

Reason:*

Dosage:*

Frequency:*

Product/Drug:

Reason:

Dosage:

Frequency:

Product/Drug:

Reason:

Dosage:

Frequency:

Product/Drug:

Reason:

Dosage:

Frequency:

SYSTEM REVIEW QUESTIONS: Do you or have you ever had any problems with the following areas (mark all that apply)?

Eyes

Ears, Nose, Mouth, Throat

Heart

Lungs/Breathing

Intestines/Bowels

Urinary

Muscles

Nerves

Joints/Bones

Skin

Internal Organs

Blood

Psychological/Emotional

FEMALE ONLY: Gynecological / Menstrual / Breast

MALE ONLY: Prostate / Testicular / Penile

Please explain any selection made:

OTHER INFORMATION:

How do you sleep?*

Please select at least one option

Back

Side

Stomach

Do you use a pillow?

Yes

Do you wear orthotics or arch supports?

Yes

Females: Date of last gynecological exam (generally)?*

Are you pregnant?*

Please select at least one option

Yes

Possibly

Date of last menstrual cycle?*

INFORMED CONSENT

Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain to obtain your informed consent before starting treatment.

I do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Physical therapy and exercises may also be used.

Although spinal and extremity manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows:

Soreness/Bruising: I am aware that like exercise it is common to experience muscle soreness and occasionally bruising in the first few treatments.

Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare.

Fractures/Joint Injury: I further understand that in isolated cases underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution.

Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I am aware that nerve or brain damage including stroke is reported once in a million to once in ten million treatments. Once in a million is about the same change as getting hit by lightning. Once in ten million is about the same chance as a normal dose of Aspirin or Tylenol causing death.

Physical Therapy Burns: Some of the therapies used in this office generate heat and may rarely cause a burn. Despite precautions, if a burn is obtained, there will be a temporary increase in pain and possible blistering. This should be reported to the doctor.

Tests have been or will be performed on me to minimize the risk of any complication from treatment and I freely assume the risk.

Please enter your name if you consent to treatment:*

TREATMENT RESULTS

I also understand that there are beneficial effects associated with these treatment procedures including decreased pain, improved mobility and function, and reduced muscle spasms. However, I appreciate there is no certainty I will achieve these benefits.

I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures.

I agree to the performance of these procedures by my doctor and such other persons of the doctor's choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me including, rest, home applications of therapy, prescription or over-the-counter medications, exercises and possible surgery.

Medications: Medication can be used to reduce pain or inflammation. I am aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate short-term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risk.

Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat or other home therapy. Prolonged bed rest contributes to weakened bones and joint stiffness. Exercises are of limited value but are not corrective of injured nerve and joint tissues.

Surgery: Surgery may be necessary for joint instability or serious disc rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.

Non-treatment: I understand the potential risks of refusing or neglecting care may include increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment making future recovery and rehabilitation more difficult and lengthy.

I have read or had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING OF THIS CONSENT FORM. I have made my decision voluntarily and freely.

To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.

Pinehurst Chiropractic Center

Authorization and Assignment

In consideration of your undertaking to care for me, I agree to the following:

You are authorized to release any information you deem appropriate concerning my physical or emotional condition and/or health history to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred.
I authorize the direct payment to you of any sum I now or hereafter owe you by my attorney out of the proceeds of any settlement of my case, and by any insurance company obligated make payment to me or you based in whole or in part upon the charges made for your services.
In the event any insurance company obligated by contractual agreement to make payment to me or to you for the charges made for your services refuse to make such payment up demand by you, I hereby assign and transfer to you the cause of action that exists in my favor against any such company (the name(s) of which is believed to be correctly set forth under pertinent data) and authorize you to prosecute said action either in my name as you see fir and further authorize you to compromise, settle, or otherwise resolve said claim as you see fit. However, it is understood that all reasonable efforts have been made to collect the sums due from the insurance company, or companies, contractual obligated, you will refrain from attempts and efforts to collect the amounts owed directly to me. I understand that whatever amounts you do not collect from insurance companies proceeds, whether it be all or part of what was due, I personally owe you.
In addition to the above, I hereby waive the statute of limitations on collections and/or recovery in this state of North Carolina.
I further agree that this Authorization and Assignment is irrevocable until all monies owed Pinehurst Chiropractic Center are paid in full.

Financial/Privacy Policy and Disclaimer

Insurance Verification

Insurance verification is not a guarantee of payment. Verification is only a quote of patient benefits. Insurance companies review charges individually and make payment accordingly. Charges not covered by insurance are the patient's responsibility and due within 30 days of billing.

Deductible Payments

It is our policy to collect at time of service. Once we receive an "Explanation of Benefits" report from the patient's insurance company, we will bill or credit the account for the remaining balance. Reimbursement checks can be issued upon request.

Collection of Patient Balance

Co-payments and Co-insurance is the patient's responsibility and will be collected at the time of service.
If the "Explanation of Benefits" report shows the patient has an outstanding balance from services not covered by the individual insurance company, patients will receive a bill outlining these outstanding charges. Upon receipt, payment is due within 30 days. After 30 days, it is the clinic's policy to turn unpaid accounts over to a collections agency. Legal fees incurred from the collections process are the responsibility of the patient in addition to the previous balance.

Returned Checks

It is our policy to collect $25.00 for checks that are returned to us. This is to cover any fees that apply from the transaction.

Appointments

If unable to keep an appointment, as a courtesy to our staff and other patients, please give 24 hour notice. There is a $25 charge added towards your account for each visit that is missed. The patient is responsible for payment.

Financial Policy Questions

We are happy to address questions regarding your account at any time. Please direct accounting questions to our billing administrator.

HIPPA Privacy Policy

Attached to the patient information packet at the back of these forms is the HIPPA Notice of Privacy Practices Policy for you.
By signing below, the patient acknowledges that he/she has received the HIPPA Privacy Policy and that he/she understands and will comply with out financial policies.

Please read and sign:

I hereby state that all information that I have provided is complete and truthful and that I fully disclosed my health history.

Signature*

Date Signed*

Printed Name*

Email*

Authorization to Release Information to Family Members

Many of our patients allow family members such as their spouse, significant other, parents or children to call and request the result of tests, procedures and financial information. Under the requirements for H.I.P.A.A. we are not allowed to give this information to anyone without the patient's consent. If you wish to have your medical information, any diagnostic test results and/or financial information released to any family members you must sign this form. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

I authorize Pinehurst Chiropractic Center to release my records and any information requested by the following individuals

Name

1. Relation to Patient:

2. Name

2. Relation to Patient:

3. Name

3. Relation to Patient:

4. Name

4. Relation to Patient:

Signature*

Date Signed*

Printed Name*

Email*

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING. By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms"). Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein. Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

THE E-SIGNATURE SERVICE.
- Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy. The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
- Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law. The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18. In order to use the Services, you must be identified by a unique email address. Two or more natural persons may not use the Services using the same set of credentials.
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You agree not to (attempt to) modify, adapt, or hack the Services. You agree not to engage in any activities that would create a false association with the Services. You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.

WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
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- Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
- If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.

CUSTOMER OBLIGATIONS.
- Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations. You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
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Review Wave is not a party to any Document executed via the Services.

Review Wave has no control over the contents of any Document. Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.

Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.

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With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements. You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.

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You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

TERM AND TERMINATION.
- Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased. Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason. Review Wave may notify you prior to any such termination or suspension at its discretion.
- Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.

INDEMNIFICATION.
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DOCUMENT RETENTION AND DATA PROTECTION.
- Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so. Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
- Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services. Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.

GENERAL.
- Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
- Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
- Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion. Your use of the Service signifies your agreement to these changes. You will be notified of material changes by notice on the website or via e-mail.
- Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave. Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion. These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
- Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email: support (at) reviewwave.com

Our Locations

Chiropractic Location
Address
315 Page Rd, Suite 11,
NC 28374

Phone
910-295-1215
Massage Location
Address
20 Memorial Drive,
Suite B,
NC 28374

Phone
910-295-1215