Patient Form

Patient Information

Name(Required)

Email(Required)

Home Phone Number(Required)

Cell Phone Number(Required)

Work Phone Number

Date Of Birth(Required)

Age(Required)

Sex(Required)

Male

Female

Employer

Occupation

Address(Required)

Name of Spouse or Parent

Referred to Barber Chiropractic by:

In Case of Emergency Contact

Name(Required)

Relationship(Required)

Home Phone:(Required)

Cell:(Required)

Work:

Insurance:

Primary Insurance

Do You Have Insurance?

Insurance Company:(Required)

ID#

Group#

Person Responsible for Account:(Required)

Birth Date:(Required)

Relationship to Patient:(Required)

Additional Insurance

Is the patient covered by additional inssurance?

Yes

If yes: Subscriber Name:

Relationship

DOB:

Address (if different from patient)

Insurance Company:

ID#

Assignment of Release

I, the undersign certify that I (or my dependent) have insurance coverage with and assign directly to Barber Chiropractic all insurance benefits, if any otherwise payable to me for services rendered. I understand that I am respnsible for all charges whether or not paid by my insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions:

Barber Chiropractic & Wellness Center - Dr. Anthony Barber

Reason for Visit:(Required)

Back Pain

Neck Pain

Mid-Back pain

Rt arm pain

Rt leg pain

Lft arm pain

Lft leg pain

Other

Other Reason for Visit:

Your pain has been as high as:(Required)

If Symptoms are due to an injury, what type of injury?(Required)

Work Related

Traffice Accident

Lifting Injury

Object fell on you

Repetitive use Injury

Not Applicable

Date of Injury

If no injury, how long have you had your pain? (select one)(Required)

Days

Weeks

Months

Years

The pain is: (select all that apply)(Required)

Continuous

Occassional

When is your pain worse? (select all that apply)(Required)

Morning

Daytime

Evening

Night-time

Describe your pain: (select all that apply)(Required)

What makes your pain worse? (select all that apply)(Required)

What makes your pain better? (select all that apply)(Required)

Medications

Bending

Lying

Sitting

Standing

Walking

Changing Positions

Nothing

What associated symptoms do you have? (select all that apply)(Required)

Numbness

Weakness

Catching

Giving Out

Do you have any unexplained fevers above 101.5F? (select)(Required)

Yes

Do you have any recent changes in controlling your bowels or bladder? (select one)(Required)

Yes

Do you have any unexplained wight loss greater than 15pounds? (select one)(Required)

Yes

What treatment have you had for this problem? (select all that apply, include first date of service & details)

Medications

Date

Results/How Long

Physical Therapy

Date

Results/How Long

Chiropractic Care

Date

Results/How Long

Injections

Date

Results/How Long

Surgery

Date

Results/How Long

Doctor

Date

Results/How Long

What treatment have you had for this problem?

Nothing

Other

What diagnostic studies have you had for this problem? (select all that apply and include date and details)

X-ray

Date

Results

MRI

Date

Results

CT Scan

Date

Results

EMG

Date

Results

What diagnostic studies have you had for this problem?

Nothing

Other

Symptoms:

Weight Gain(Required)

Yes

Rash(Required)

Yes

Visual Disturbances(Required)

Yes

Sore Throat(Required)

Yes

Shortness of Breath(Required)

Yes

Cough(Required)

Yes

Chest Pain(Required)

Yes

Cold Hands/Feet(Required)

Yes

Constipation(Required)

Yes

Incontience of Bowel(Required)

Yes

Incontience of Bladder(Required)

Yes

Nausa(Required)

Yes

Muscle Weakness(Required)

Yes

Balance Problems(Required)

Yes

Seizures(Required)

Yes

Sleep Disturbance(Required)

Yes

Feelings of Sadness(Required)

Yes

Apetite Changes(Required)

Yes

Abnormal Bleeding(Required)

Yes

Are you Currently Pregnant?(Required)

Yes

Unknown

Tabacco Use:(Required)

None

Smoke

Chew/Dip

Alcohol Use:(Required)

Yes

What is your occupation?(Required)

Are you currently working?(Required)

Yes

Retired

Have you had any Surgeries?

Yes

Surgeries you have had:(Required)

Do you have any past injuries or accidents?

Yes

Past Injuries/Accidents:(Required)

Do you have any Allergies

Yes

Allergies (please list all allergies to medications and contactants)(Required)

Please provide any concerns or comments:

Medical History/Family History: (Select if apply for you or a family member)

History of Back Pain(Required)

You

Family

None

Cancer(Required)

You

Family

None

Heart Disease(Required)

You

Family

None

High Blood Pressure(Required)

You

Family

None

Diabetes(Required)

You

Family

None

High Blood Fats/Cholesterol(Required)

You

Family

None

Vein Trouble/Blood Clots(Required)

You

Family

None

Stroke/TIA(Required)

You

Family

None

Asthma(Required)

You

Family

None

Sleep Apnea(Required)

You

Family

None

Lung Disease(Required)

You

Family

None

Esophageal Reflux/Stomach Ulcer(Required)

You

Family

None

Liver Disease/Hepatitis(Required)

You

Family

None

Kidney/Bladder Disease(Required)

You

Family

None

Abnormalities of Female Organs(Required)

You

Family

None

Abnormalities of Prostate(Required)

You

Family

None

Thyroid Disease(Required)

You

Family

None

Abnormal Bleeding(Required)

You

Family

None

Blood Problems (Anemia, High/Low, White Count)(Required)

You

Family

None

Joint Disease(Required)

You

Family

None

Anxiety/Depression/Psychiatric Illness(Required)

You

Family

None

History of Substance Addiction(Required)

You

Family

None

Skin Disease(Required)

You

Family

None

Other Symptoms:

Medications: (please list ALL of your current medications, including over-the-counter medications and vitamins. Please list dosages and how often you take your medications and vitamins.)

Name

Dose

Frequency

BARBER CHIROPRACTIC & WELLNESS CENTER
2067 STATE ROUTE 130 JEANETTE, PA 15655

DR. ANTHONY BARBER
DR. KRISTOPHER PISCZEK

HIPAA COMPLIANCE PATIENT CONSENT FORM

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?(Required)

Yes

May we leave a message on your answering machine at home or on your cell phone?(Required)

Yes

May we discuss your medical condition with any member of your family?(Required)

Yes

If YES, please name the members allowed:

Patient Forms

Patient Form

Patient Information

In Case of Emergency Contact

Insurance:

Assignment of Release

Barber Chiropractic & Wellness Center - Dr. Anthony Barber

What treatment have you had for this problem? (select all that apply, include first date of service & details)

Medications

Physical Therapy

Chiropractic Care

Injections

Surgery

Doctor

What diagnostic studies have you had for this problem? (select all that apply and include date and details)

X-ray

MRI

CT Scan

EMG

Symptoms:

Medical History/Family History: (Select if apply for you or a family member)

Medications: (please list ALL of your current medications, including over-the-counter medications and vitamins. Please list dosages and how often you take your medications and vitamins.)

BARBER CHIROPRACTIC & WELLNESS CENTER
2067 STATE ROUTE 130 JEANETTE, PA 15655

DR. ANTHONY BARBER
DR. KRISTOPHER PISCZEK

HIPAA COMPLIANCE PATIENT CONSENT FORM

Barber Chiropratic | Location Information

Patient Form

Patient Information

In Case of Emergency Contact

Insurance:

Assignment of Release

Barber Chiropractic & Wellness Center - Dr. Anthony Barber

What treatment have you had for this problem? (select all that apply, include first date of service & details)

Medications

Physical Therapy

Chiropractic Care

Injections

Surgery

Doctor

What diagnostic studies have you had for this problem? (select all that apply and include date and details)

X-ray

MRI

CT Scan

EMG

Symptoms:

Medical History/Family History: (Select if apply for you or a family member)

Medications: (please list ALL of your current medications, including over-the-counter medications and vitamins. Please list dosages and how often you take your medications and vitamins.)

BARBER CHIROPRACTIC & WELLNESS CENTER 2067 STATE ROUTE 130 JEANETTE, PA 15655

DR. ANTHONY BARBER DR. KRISTOPHER PISCZEK

HIPAA COMPLIANCE PATIENT CONSENT FORM

Barber Chiropratic | Location Information

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BARBER CHIROPRACTIC & WELLNESS CENTER
2067 STATE ROUTE 130 JEANETTE, PA 15655

DR. ANTHONY BARBER
DR. KRISTOPHER PISCZEK