SELANO CHIROPRACTIC CENTER

PATIENT INFORMATION SHEET PATIENT: (Please provide you legal name as it appears on your insurance card or ID) Last Name: First Name: Middle: Home Address: Apt #: City: State: Zip: Can we leave a limited message on your voice mail? Yes or No Who can we speak with regarding your account? What is the best time of day to reach you? Morning lam-12pm Afternoon 12:30-5:OOpm Evening 5:30pm-8:30pm Home #: Work #: Ext Cell #: Employer Name: Occupation: DOB: / / SS #: Gender: M F Marital Status: M S D W GUARDIAN OR RESPONSIBLE PARTY: Complete this section if you are not the patient but are responsible for the bill. RP Last Name: First Name: Middle: Home Address: Relationship to Patient: Home #: Work #: Ext Cell #: Employer Name: Occupation: DOB: / / SS #: Gender: M F Marital Status: M S D W INSURANCE: (please list Primary policy holder's information if other than patient, and provide a copy of your card) 1 st Insurance Company: Phone #: Insured's Name: ID/Policy #: GRP #: DOB: / / SS #: Gender: M F 2nd Insurance Company: Phone #: Insured's Name: ID/Policy #: GRP #: DOB: / / SS #: Gender: M F

**Is today's visit due to a Current Workers Comp or Motor Vehicle accident? If yes, please mark the correct case. Date of Accident Let us know after finishing your paperwork so that we may get additional information from you. **

Payment for services rendered: Selano Chiropractic Center as a courtesy to our patients will attempt to obtain payment from the above listed Insurance Carrier, Workers Compensation plan, and/or Motor Vehicle Insurance. It is our policy to complete an initial claim form and submit it to your carrier. We will make our best effort to secure said payment from your carrier. However, please be sure to check with your carrier to resolve any issue that may arise. If you have no insurance we do expect payment at the time of service. EMERGENCY: Name and address of nearest relative or friend not living with you. Last Name: First Name: Middle: Home #: Work Phone #: Relation to Patient: Authorization I hereby assign, transfer and set over to Selano Chiropractic Center and its individual providers, all my rights, title, and interest to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until written notice is given by me revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. Signature: (Patient, Parent, Legal Guardian or Responsible Party)

I request services X Date

❑ 76 — 100% (Constant)

INITIAL HEALTH STATUS

Patient Name: Birthdate: Sex: M / F

MARK AN X ON THE PICTURE WHERE YOU HAVE PAIN OR OTHER SYMPTOMS .

DESCRIBE YOUR CURRENT PROBLEM AND HOW IT BEGAN: ❑ Headache ❑ Neck pain ❑ Mid-back pain ❑ Low back pain

Other

Date Problem Began: How Problem Began:

Current complaint (how you feel today):

0 1 2 3 4 5 6 7 8 9 10 No Pain Unbearable Pain

How often are your symptoms present? (Intermittent) ❑ 0 - 25% ❑ 26 — 50% ❑ 51 — 75%

In the past week. how much has your pain interfered with your daily activities (e.g., work, social activities. or household chores? I I

No interference 0 1 2 3 4 5 6 7 8 9 10 Unable to carry on any activities

HAVE YOU HAD SPINAL X-RAYS, MRI, CT SCAN FOR YOUR AREA(S) OF COMPLAINT? [1] No ❑ Yes

Date(s) taken: What areas were taken?

Please check all of the following that apply to you: ❑ Recent Fever ❑ Prostate Problems ❑ Diabetes ❑ Menstrual Problems ❑ High Blood Pressure 11] Urinary Problems [1] Stroke (date) ❑ Currently Pregnant, # weeks ❑ Corticosteroid Use (cortisone, prednisone, etc.) ❑ Abnormal Weight ❑ Gain ❑ Loss ❑ Taking Birth Control Pills ❑ Marked Morning Pain/Stiffness

Dizziness/Fainting ❑ Pain Unrelieved by Position or Rest ❑ Numbness in Groin/Buttocks E Pain at Night ❑ Cancer/Tumor (explain) ❑ Visual Disturbances

❑ Surgeries ❑ Osteoporosis

Epilepsy/Seizures ❑ Other Health Problems (explain) ❑ Medications:

Family History: ❑ Cancer Heart Problems/Stroke ❑ Rheumatoid Arthritis

I certify that the above information is complete and accurate. I agree to notify this doctor immediately whenever I have changes in my health condition in the future.

Diabetes 0 High Blood Pressure

Patient Signature: Date:

Review of Systems

Patient Name: Patient File #: Today's Date:

/

INSTRUCTIONS: Please fill out all of the sections. If none of the conditions apply, select "None."

Constitutional: ....None

Chills _Daytime Drowsiness

Fatigue ...Fever :Night Sweats _Weight Gain ,.Weight Loss

Eyes/Vision: :None :Blindness -_Blurred Vision TCataracts _ Change in Vision :Double Vision _Eye Pain

Field Cuts Glaucoma

:Itching (around the eyes)

_ Photophobia _Tearing Li Wears Glasses or Contacts

Ears, Nose and Throat: None

_ Bleeding _ Dental Implants 7Dentures ..Difficulty Swallowing _Discharge _ Dizziness _Ear Drainage -Ear Infection(s) _Ear Pain -Fainting

Headaches -Head Injury (history of)

_Hearing Loss ,:-Hoarseness _Loss of Smell _Nasal Congestion .✓Nose Bleeds -Post Nasal Drip -Rhinorrhea (runny nose)

Sinus Infections .Snoring _Sore Throats -Tinnitus (ringing in the ears) _TMJ Disorder

Respiration: -None :Asthma _Coughing up blood _ Shortness of Breath :Sputum Production

Wheezing

Cardiovascular: ...None

Angina (chest pain or discomfort)

...Chest Pain Claudication (leg pain or achiness)

..Heart Murmur L_Heart Problems

Orthopnea (difficulty breathing while lying) :Palpitations (irregular or forceful

heart beat) :Paroxysmal Nocturnal Dyspnea (shortness of breath at night)

_Shortness of Breath _Swelling of Leg(s) _Ulcers _Varicose Veins

Gastrointestinal: _None _ Abdominal Pain . Belching _Black, Tarry Stools _Constipation _Diarrhea _Difficulty Swallowing .,Heartburn _ Hemorrhoids -Indigestion _Jaundice (yellowing of the skin)

aNausea _ Rectal Bleeding _Abnormal Stool Caliber (quality) _Abnormal Stool Color _Abnormal Stool Consistency _Vomiting -_-_,Vomiting Blood

Female: _.None -Birth Control Therapy

Breast Lumps / Pain -Burning Urination _Cramps _Frequent Urination .._Hormone Therapy _Irregular Menstruation _Urine Retention _Vaginal Bleeding ...Vaginal Discharge

Male: -None -Burning Urination _ Erectile Dysfunction „-Frequent Urination _ Hesitancy or Dribbling _Prostate Problems _Urine Retention

Endocrine: ZNone _Cold Intolerance :;.Diabetes _Excessive Appetite :Excessive Hunger --Excessive Thirst ;Frequent Urination ._Goiter _Hair Loss ....Heat Intolerance -.Unusual Hair Growth _Voice Changes

Skin: None

...Changes in Nail Texture ...:Changes in Skin Color ...Hair Growth _ Hair Loss _;;Hives

Itching _Paresthesia (numbness, prickling, or tingling)

Rash History of Skin Disorders

_Skin Lesions or Ulcers ;Varicosities

Nervous System: -None

Dizziness .:.Facial Weakness _ Headaches ...Limb Weakness _ Loss of Consciousness -_ Loss of Memory _Numbness

_Seizures ....Sleep Disturbance -Slurred Speech

Stress -Strokes _Tremors _Unsteadiness of Gait

Psychological: I.None .-Anhedonia (inability to experience

joy or enjoy life) .,Anxiety _Appetite Changes ...Behavioral Change(s) __Bipolar Disorder ...Confusion

Convulsions _Depression _Insomnia _Memory Loss _ Mood Change(s)

Allergy: :None

Anaphylaxis (history of)

_Food Intolerance Itching Nasal Congestion

I, Sneezing

Hematology: 'None

_Anemia :Bleeding

Blood Clotting Blood Transfusion(s)

_Bruises easily _ Fatigue

Lymph Node Swelling

Selano Chiropractic Center, Inc. 243 Merchants Dr. Dallas, GA 30132 770-445-1362 Front Office 770-445-5860 Fax

Dr. Jeff Selano DC -Clinic Director

Dr. Tammie McCallie DC

Patient Consent Form

This form is for the use and or disclosure of Protected Health Information (PHI) to carry out Treatment, Payment and Health Care Options.

hereby state that by signing this consent, I acknowledge and agree as follows:

1. The practices Privacy Notice has been provided to me prior to my signing this consent. The Privacy Notice includes a complete description of the uses and or disclosures of my PHI necessary for the Practice to provide treatment to me, and also necessary for the Practice to obtain payment for that treatment, and to carry out it's day to day healthcare operations. The Practice explained to me that the Privacy Notice would be available to me in the future at my request. The Practice has further explained my right to obtain a copy notice prior to signing this consent, and has encouraged me to read the Privacy Notice carefully prior to my signing this consent.

2. The Practice reserves the right to change its Privacy Practices that are described in its Privacy Notice, in accordance with applicable law.

3. I understand that, and consent to, the following appointment reminders or communications that will be used by the Practice:

a. Appointment cards b. Phone calls to a phone number you designate or place of work regarding

payment or appointments upcoming or missed. c. Sign in sheets in the front lobby d. Charts placed in the door of the treatment rooms e. General information will be given out to people who ask for you by name

Example: You're on the property or when you are expected. 4. The Practice may use and or disclose my PHI ( which includes information about

my health or condition and the treatment provided to me, in order for the Practice to treat me and obtain payment for that treatment, and as necessary for the Practice to conduct its specific health care operations.)

5. I understand that I have a right to request that the Practice restrict how my PHI is used or disclosed to carry out treatment, payment and or health care operations. However, the Practice is not required to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.

6. I understand that this Consent is valid for Seven Years. I further understand that have the right to revoke this Consent, in writing, at any time for all future transactions, with the understanding that any such revocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.

7. I understand that if I revoke this Consent at any time, the Practice has the right to refuse to treat me,

8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contain in the Privacy Notice, then the Practice will not treat me.

I have read and understand the foregoing notice, and all of my questions have been answered to my full satisfaction in a way that I can understand.

Name of individual (printed) Signature of individual

Signature of Legal Representative Relationship

Date Witness

CONSENT FOR TREATMENT

I, the undersigned, hereby authorize Selano Chiropractic Center to perform diagnostic tests, including but not limited to radiographs, and administer treatment as is necessary. I, also, certify that no guarantee or assurance has been made to the results that may be obtained.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that my amount authorized to be paid directly to this office will be credited to my account upon receipt. I permit this office to endorse remittances for the conveyance of credit to my account.

PATIENT SIGNATURE

DATE WITNESS

SELANO CHIROPRACTIC CENTER

Payment Policy Thank you for choosing Selano Chiropractlt Center as your Chiropractic provider. We are

committed to providing you with affordable health care. Because some of our patients have had questions regarding patient and insurance responsibility for services rendered, we have been advised to develop this payment policy. Please read it, ask us any questions you may have, and sign in the space provided. A copy will be provided to you upon signature.

1. Insurance. We participate in most insurance plans, including Medicare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, but don't have an up-to-date insurance card, payment in full for each visit is required until we can verify your coverage. Knowing your insurance benefits is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage.

2. Co-payments and deductibles. All co-payments and deductibles must be paid at the time of service.

3. Non-covered services. Please be aware that some - and perhaps all - of the services you receive may be non-covered or not considered reasonable or necessary by Medicare or other insurers. You must pay for these services in full at the time of visit.

4. Proof of insurance. All patients must complete our patient information form before seeing the doctor. We must obtain a copy of your driver's license and current valid insurance to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim.

5. Claims submission. We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not party to that contract.

6. Coverage changes. If your insurance changes, please notify us before your next visit so we can make the appropriate changes to help you receive your maximum benefits.

7. Nonpayment. Partial payments will not be accepted unless otherwise negotiated. Please be aware that if a balance remains unpaid, we may refer your account to a collection agency and you may be discharged from this practice. If this is to occur, you will be notified by regular or certified mail that you have 30 days to find alternate medical care.

8. Missed appointments. It is not our policy to charge for missed appointments. However, we do ask that you call us to cancel your appointment at least 24 hours in advance, or as soon as possible so that someone else might have the opportunity to use that time slot.

9. Non Sufficient Funds Checks. Our policy is to attempt to secure funds from all checks written. If they fail on the first attempt our bank will automatically send it through a second time. If it is returned to us we will charge our bank fees plus $25 to your account.

Our practice is committed to providing the best treatment to our patients. Our prices are representative of the usual and customary charges for our area. Thank you for understanding our payment policy. Please let us know it you have any questions or concerns. I have read and understand the payment policy and agree to abide by it's guidelines:

Signature of patient or responsible party Dated

Name of Patient Date

WHAT TO EXPECT AFTER YOUR FIRST ADJUSTMENT

Please read the following information carefully. Sign the bottom of the sheet to indicate that you understand the instructions and information given.

1. If you have never been adjusted, or if it has been awhile since your last adjustment, you may experience soreness or discomfort for a few hours to a few days. This is a normal reaction to chiropractic adjustments.

2. If you are sore, use ice packs on the affected area. Ice therapy consists of the use of ice packs at 10 minutes intervals followed by 40 minutes of rest. This can be repeated as often as needed. Do not apply ice directly to bare skin. Always protect skin with a thin covering such as a shirt or light towel. Cover the ice pack with a thick towel to retain the cold.

3. Do not use heat except under the doctor's instruction. Heat may aggravate your injury by causing inflammation.

4. Stay away from heavy lifting or repetitive movements until the doctor indicates you are ready for normal activities. Strenuous athletic activities such as running, lifting weights, impact aerobics, racquetball, tennis, skiing, bowling, etc. should be avoided. Other things to avoid are yard work such as raking, digging, lifting heavy objects such as groceries, pets and children, and any other activities that could aggravate or re-injure your condition.

5. Unless indicated by the doctor, you may return to work/school after your appointment

6. If a sudden movement causes sharp or severe pain, or if you experience swelling, contact the clinic at 770-445-1362. After hours, contact Dr. Tammie McCallie at 770-722-3234.

I have read and understand the instructions given for my follow-up care.

Patient's Signature Date