Munday Chiropractic Clinic, P.A.

Today’s Date: ____________________ Email:___________________________ Name: ________________________ DOB: _______ Sex: M F Last 4 #’s of SS#: _______

Address ____________________________________________City _________________State _____ Zip ________ Phone #’s: Cell: __________________ Home: ________________ Work: ________________

Employer __________________Occupation ______________Address ______________________ Ph ___________

Spouse __________Employer _________ Emergency Contact_______________Ph__________Relation__________

HEALTH INSURANCE INFORMATION: Your PRIMARY insurance Co____________________ Policyholder’s name &

DOB_______________________ Policyholder’s relation to patient_________ Policyholder’s employer __________

ACCIDENT INFORMATION : Auto Work Slip & Fall *Date and place of injury _____________________________

Auto/work insurance Co.____________________ Insured’s Name and DOB ________________________________

Accident reported to your insurance Co or Boss? Yes No, Claim# _____________________ Please provide dates

and details of ALL prior accidents_________________________________________________________________

HISTORY of 1st COMPLAINT: Where is your WORST symptom:_______________________________________________

How long have you had it: _____________________ How did it start: ______________________________________

Is it: Improving or Worsening or Staying the Same Is it: Mild or Moderate or Severe

What WORSENS it: Activity Moving wrong Bending Lifting Walking Sports Getting up from a chair

Using a computer and/or deskwork Performing your work duties Other:__________________________________

What IMPROVES it: Rest Activity Ice packs Heating pad Over-the-counter meds Prescription Meds

Massages Past chiropractic care Physical Therapy Other: ____________________________________________

Is it worse in the: Morning time Night Time After day wears on Fairly Steady Off and on with no pattern

Is it: Dull & achy Tight & stiff Sharp and stabbing Numb & tingly Shooting Burning Cramping

HISTORY of 2nd COMPLAINT: Where is your SECOND WORST symptom:___________________________________

How long have you had it: _____________________ How did it start: ______________________________________

Is it: Improving or Worsening or Staying the Same Is it: Mild or Moderate or Severe

What WORSENS it: Activity Moving wrong Bending Lifting Walking Sports Getting up from a chair

Using a computer and/or deskwork Performing your work duties Other:__________________________________

What IMPROVES it: Rest Activity Ice packs Heating pad Over-the-counter meds Prescription Meds

Massages Past chiropractic care Physical Therapy Other: ____________________________________________

Is it worse in the: Morning time Night Time After day wears on Fairly Steady Off and on with no pattern

Is it: Dull & achy Tight & stiff Sharp and stabbing Numb & tingly Shooting Burning Cramping

Medicare Patients ONLY (check ONLY ONE that you would like to be able to do without pain)

___ bend and lift ___read ___get up from sitting ___ get a good night’s sleep ___work at a computer

___do housework ___ do yard work ___ play sporting activities

Page 1

CURRENT HEALTH HISTORY Name, address and ph# of your family doctor___________________________________________________

List all CURRENT illness or disease you are experiencing (such as cancers, tumors, infections, aneurysms,

diabetes, liver/kidney disease) etc: ___________________________________________________________

____________________________________________________ Date of last eye exam: ________________

List Blood Thinners:______________ Please list medication allergies:_______________________________

Please list your Height ________ Weight__________ What is your usual blood pressure ________/________

PAST HEALTH HISTORY Please list past operations, surgeries or medical procedures you have had:

Date:__________Procedure:______________________Date:__________Procedure:___________________

Date:__________Procedure:______________________Date:__________Procedure:___________________

Please list all past or current illnesses, such as cancers, bone tumors, infections, aneurysms, stents, injuries:

Date:__________Condition:______________________Date:__________Condition:___________________

Date:__________Condition:______________________Date:__________Condition:___________________

Recent loss of bowel/bladder control: Y N Recent seizures, paralysis, speech or vision problems: Y N

Any unexplained recent weight loss: Y N Current fever: Y N

List any blood or lymph node disorders ________________________

Do you have osteoporosis: Y N List any skin, hair or nail disorders _______________________________

Do you have a Pacemaker or other electric device that you currently wear? Y N If yes, please Alert us NOW

Circle ONE: I never smoked Former smoker Current smoker, if so how much: __ pack/day or __pack/wk

Circle ONE: I don’t drink any alcohol Rarely drink Social/moderate drinker Heavy drinker: (___oz/day/wk)

Have you ever had Chiropractic care? Y N If yes, last date of treatment ________Date of x-rays:__________

By whom? Dr. _____________Similar or Different condition?_______________Results _________________

What are your overall expectations from your visit/treatment with Dr. Munday? _________________________

__________________________________________________________________________________________ I, the undersigned, hereby give my consent for the Doctor to examine and treat my condition as he deems appropriate through the

use of Chiropractic and/or massage therapy care. I give my consent to the Doctor to take x-rays (if needed) or to perform other

diagnostic aids as deemed appropriate in my case. I also understand that treatment may result in temporary bruising, increased

pain or discomfort, and/or aggravation of symptoms.

Women Only: I hereby declare that to the best of my knowledge, ___I am or ___I am not pregnant. If there is a chance that I

may be pregnant, I will inform the Staff and/or Doctor prior to my examination.

Patient's Signature _______________________________________________________________ (Parent/Guardian signature if patient is under 18 years of age)

Page 2

GENERAL/FINANCIAL POLICY

Welcome to Munday Chiropractic Clinic, P.A. We strive to provide you with excellent Chiropractic care in a clean, friendly, professional setting.

By signing below, you confirm that you have read this policy and understand that:

It is your responsibility to inform our office of any address or telephone number changes.

Your account is to be kept current. All self pay, insurance copayments, co-insurances and deductibles will be collected at the time of service payable by cash, check, or credit card. For your convenience, we can store your credit card on file.

If you are unable to keep a massage appointment, please notify us 24 hours before your appointment so that we may offer that time to another patient. We will try to fill your missed spot with another patient, but in the event that we are unable to do so, there is a $20 fee for missing a 30 minute massage, a $30 fee for missing a 45 minute massage, and a $40 fee for missing a 60 minute massage without a 24 hour notice. If a massage is missed without proper notification, all future massage appointments must be secured with a credit card on file. In the event you miss any future massages without proper notice, you agree for us to charge your card the missed fee. Initial here: ______

If you have a Health Savings Account that pays for your services when the claim is submitted, you must secure a credit card on file. In the event your fund is depleted when we submit our claim, the unpaid balance will then be settled with your credit card we have on file. We will call you to inform you of such charge. Initial here: ______

If you believe that your deductible has been met, even after we verify with your health insurance company that it is not yet met, you will be required to pay for your services at the time of your visit. In the event that our claim is paid, you will have a credit on your account. Initial here: ______

Returned checks will result in a $25.00 service fee and all future payments will be in the form of cash or credit card.

You will only be sent a statement if your balance exceeds $10.00.

There is a $15 charge for the completion of paperwork such as Disability Forms and FMLA forms.

If your account is turned over to a collection agency, you will be responsible for any costs incurred in collection of funds.

IF YOU HAVE HEALTH INSURANCE COVERAGE: As a courtesy to you, our office will attempt to pre-verify your primary insurance coverage for your Chiropractic care. Coverage information is obtained from your insurance company using information provided by you prior to your initial visit. We must emphasize that as medical providers, our relationship is with you, not your insurance company. Please be advised that the information provided by your insurance company is not a guarantee of payment, only an estimate of what might be covered under your policy at the time of inquiry. You will be responsible for any unpaid amounts.

By signing below you confirm you understand that: It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified.

Not all services are a covered benefit with all insurance plans. We will do our best to inform you of non-covered services.

It is your responsibility to be aware of what service (s) is being provided to you and if it is a covered benefit under your insurance.

You are responsible for any non-covered services not payable by your insurance policy.

We will send all required claim forms and documentation to ensure your claims are processed in a timely manner.

Final determination of benefits available is determined when the claim is sent to your insurance company and we receive an explanation of benefits from them. After all co-pays, contracted plan reductions and insurance payment credits are applied to your account, any remaining portion will be your responsibility. We will attempt to contact you in order to collect any unpaid amounts on your account, but if we are unable to contact you or we have had no response to mailings and/or phone calls, you agree for us to bill your credit card on file for any unpaid amounts. Before billing your card, we will send a letter to the address we have on file informing

you that we will bill your card within 14 days of mailing. By initialing here you agree to this policy. Initial here: ______

If you are a MEDICARE PATIENT, please be advised that Medicare only covers Spinal Adjustments in a Chiropractor’s office. All services other than the Spinal Adjustment will be your financial responsibility.

By signing below, you have read and understand the above Financial Policy and agree to meet all financial obligations. ________________________________________ ____________________________________________ ________________ Printed Name Signature of Patient/Legal Guardian Date CONSENT TO RELEASE INFORMATION: In the event that you ever wish to have a family member/friend come to our office and get a copy of your medical records for whatever reason, we ask that you sign below allowing them to do so. ________________________________________ ____________________________________________ ________________ Name of Family Member/Friend Signature of Patient/Parent/Legal guardian Date CONSENT TO TREAT A MINOR: I hereby authorize and give consent for the Chiropractic Physicians at Munday Chiropractic Clinic to examine, and if needed, treat my minor child _____________________________________________.

Print child’s name here ________________________________________ ____________________________________________ ________________ Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian Date

MUNDAY CHIROPRACTIC CLINIC, P.A.

Patient Consent for Use and Disclosure

of Protected Health Information

I hereby give my consent for Munday Chiropractic Clinic, P.A. to use and disclose

protected health information (PHI) about me to carry out treatment, payment and health care operations (TPO).

(The Notice of Privacy Practices provided by Munday Chiropractic Clinic, P.A. describes such uses and

disclosures more completely.)

I have the right to review the Notice of Privacy Practices prior to signing this consent. Munday Chiropractic

Clinic, P.A. reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy

Practices may be obtained by forwarding a written request to:

Munday Chiropractic Clinic, P.A.

6645 N. Socrum Loop Rd,

Lakeland, Fl 33809

(863) 853-3000

With this consent, Munday Chiropractic Clinic, P.A. may call my home, mobile phone, or other alternative

locations and leave a message on voice mail or in person in reference to any items that assist the practice in

carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care,

including laboratory test results, among others.

With this consent, Munday Chiropractic Clinic, P.A. may mail to my home or other alternative locations any

items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as

long as they are marked “Personal and Confidential.”

With this consent, Munday Chiropractic Clinic, P.A may e-mail my home or other alternative locations or text

to my mobile phone any items that assist the practice in carrying out TPO, such as appointment reminders,

portal log-in requests, and patient statements. I have the right to request that Munday Chiropractic Clinic, P.A.

restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested

restrictions, but if it does, it is bound by this agreement.

By signing this form, I am consenting to allow Munday Chiropractic Clinic, P.A. to use and disclose my PHI to

carry out TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in

reliance upon my prior consent. If I do not sign this consent, or later revoke it, Munday Chiropractic Clinic,

P.A. may decline to provide treatment to me.

_______________________________

Signature of Patient or Legal Guardian

_______________________________ ______________________

Print Patient’s Name Date