CHIROPRACTIC

Health

C E N T R E
Thank you for choosing our team. How did you find out about us?

Were you referred by a patient who has seen us? Who?

PATIENT INFORMATION

First Name:

Last Name:
Phone #:

(H)
(W)
(C)

Postal Code:

Cellular provider: Bell

(for text reminders)

Phone

Reminder Pref.:

Would you like digital receipts? Y

(mm/dd/yyyy)

Address:

E-mail:

Birthday:

Text

E-mail

Would you like to receive newsletters & updates via e-mail? Y

Marital Status:

Occupation:
AHC #:

CL

None
N

# of children:

Emergency Contact:
Phone #:
HEALTH CLAIM INFORMATION
Y

Do you have extended health benefits?

Would you like to use direct billing?

We offer direct billing for the following companies*:

Johnson Inc

If 'Yes' please provide the following information:

Benefits Provider
Plan Member Name
ID #

You are encouraged to bring your insurance

card with you to ensure we have the correct
information.

Group/Policy/Contract #

* Please note:
a) Desjardins only allows for the plan member to receive reimbursement, therefore all fees incurred are still the patient's responsibility.
b) Manulife members must first authorize electronic statements through the plan member site in order to be eligible for these services.
c) In addition we are permitted to offer these services to RCMP, Canadian Forces & Veteran's Affairs. If unsure of your benefit
eligibility, it is advised that you speak with your benefits provider or our front desk staff for assistance; pre-authorization requirments
may apply.

If you are here for a claim, please specify what type:

MVA

WCB

TODAY'S VISIT
Reason for appointment:
How long have you had symptoms?
How frequent are your symptoms?
Have you experienced similar symptoms in the past?

Is this condition related to:

Auto
Date of accident/injury:
Work
Please list any other healthcare professionals you are seeing for this condition:
Ph: (403) 277-9339
Fx: (403) 277-2447

www.chiro-doctor.com

2713 Centre St NW
Calgary, AB T2E 2V5

CHIROPRACTIC

Health

C E N T R E
YOUR HEALTH HISTORY
If anything in this section doesn't apply to you, please put N/A in the space provided.

Have you had previous chiropractic care? Y N

Doctor's name:
Have you had X-Rays, MRI or other tests for this condition? Y N
Please list any surgeries and their dates:

When?

Where?

Please list any major injuries or illnesses and their dates:

Please list ALL medications you are taking (Prescription & Non-prescription):

These conditions are extremely important to your chiropractic care.

Please be thorough. Mark whether you've experienced these conditions in the past and/or are presently.
Past Present

Low blood pressure

High blood pressure
Diabetes
Tuberculosis
Cancer
If yes, where?
Stroke
Has a relative had a stroke?
Who?
Bone spurs in neck
or cervical sprain

Past Present

Past Present

Fainting
Smoker
For how long?
Speech problems
Difficulty swallowing

Whiplash injury
Hardening of arteries
Visual disturbances
Hearing disturbances
Heart or blood disease

Dizziness

Loss of consciousness
Sudden collapse without
loss of consciousness
Numbness or weakness in the face, fingers, hands, arms,
legs, or other extremities

Indicate the location(s)

where you have pain.

On a scale of 1 to 10,
(1 being no pain),
how severe is your pain?

Ph: (403) 277-9339

Fx: (403) 277-2447

www.chiro-doctor.com

2713 Centre St NW
Calgary, AB T2E 2V5

CHIROPRACTIC

Health

C E N T R E
Please mark whether you have experienced these symptoms in the past and/or are presently:
Past Present

Chronic cough

Sweats

Spitting up phlegm

Sleep disturbance

Fatigue
Nervousness
Weight change
Allergies

Chest pain
Wheezing
Difficulty breathing

Frequent urination

Asthma

Past Present

Blood in urine
Pus in urine
Kidney infection/Kidney stones

Prostate trouble

Past Present

Rapid heart rate

Convulsions

Difficult digestion

Slow heart rate

Headache

Pain over heart

Neuralgia (nerve pain)

Heartburn
Nausea
Vomiting
Constipation
Diarrhea
Blood in stool

Swollen ankles
Poor circulation
Palpitations
Varicose veins

NEUROLOGICAL

Poor appetite

Weakness

Past Present

Colitis
Past Present

Poor coordination

Cold hands or feet

Gallbladder/jaundice

Hot flashes
Irregular cycle

Past Present

Cramps or back pain

Double vision

Low back pain

Vaginal discharge

Ringing in ears

Arm pain

Nipple discharge

Deafness

Shoulder pain

Lumps in breast

Trouble swallowing

Hoarseness
Sinus infection

Leg pain
Knee pain
Foot pain
Pain between shoulders

*WOMEN ONLY*

Neck pain

MUSCLE & JOINT

Eye pain

Nosebleeds
EENT

Painful urination

Uncontrollable urine flow

Past Present

CARDIOVASCULAR

GASTROINTESTINAL

Spitting up blood

Past Present

GENITOURINARY

Fever
RESPIRATORY

GENERAL SYMPTOMS

Past Present

Painful menstruation
Birth control
Type?
Complications with

Nasal drainage

Fractures

pregnancy

Enlarged glands

Swollen joints

Pregnant

Spinal curvature
Arthritis
Ph: (403) 277-9339
Fx: (403) 277-2447

www.chiro-doctor.com

Weeks?
Menopausal symptoms
2713 Centre St NW
Calgary, AB T2E 2V5

CHIROPRACTIC

Health

C E N T R E
Canadian Chiropractic Protective Association

Informed Consent to Chiropractic Treatment, Form L

There are risks and possible risks associated with manual therapy techniques used by doctors of
chiropractic. In particular you should note:
a) While rare, some patients may experience short term aggravation of symptoms or muscle and
ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures
have also been known to occur following certain manual therapy procedures.
b) There are reported cases of stroke associated with visits to medical doctors and chiropractors.
Research and scientific evidence does not establish a cause and effect relationship between chiropractic
treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical
and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in
progress. However, you are being informed of this reported association because a stroke may cause
serious neurological impairment or even death. The possibility of such injuries occuring in association
with upper cervical adjustment is extremely remote.
c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal
adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused,
by spinal adjustments or other chiropractic treatment.
d) there are infrequent reported cases of burns or skin irritation in association with the use of some
types of electrical therapy offered by some doctors of chiropractic.
I acknowledge I have read this consent and I have discussed, or have been offered the opportunity
to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including
spinal adjustment), the treatment options and recommendations for my condition, and the contents of
this consent.
I consent to the chiropractic treatment recommended to me by my chiropractor including any
recommended spinal adjustments.
I intend this consent to apply to all my present and future chiropractic care.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original.

Patient/Legal guardian signature

Witness signature

Printed name

Witness name
Date

Ph: (403) 277-9339

Fx: (403) 277-2447

www.chiro-doctor.com

2713 Centre St NW
Calgary, AB T2E 2V5

CHIROPRACTIC

Health

C E N T R E
All fees incurred for treatment are payable upon services rendered.
Fee schedule is as follows:

Adult
Senior (65 & over)
Student (13-17)
Child (12 & under)

Initial Visit
$109
$89
$89
$74

Subsequent Visits
$55
$44
$44
$35

Cancellation Policies
We appreciate your decision in making us your choice in chiropractic, please respect the
needs of our other patients and make any appointment cancellations in a timely manner. We require at
least 24 hours notice for any appointment changes or cancellations. Any late cancellations or no shows
will be billed for the full price of their office visit. Please note that missed or cancelled appointments
will be your responsibility as they are not eligible for reimbursement through any health benefits provider.
If care is suspended or terminated, any and all oustanding charges for professional services rendered to or
for you will be immediately due and payable to the clinic.
Privacy Policies
We maintain a very high standard for the protection of the confidentiality and integrity of
individual personal health information. If any identifying health information is to be disclosed to another
party or we require information to be released to us for the purposes of providing ongoing care; express
written consent will be obtained. If you have any questions regarding your privacy concerns, feel free to direct
any inquiries to the front desk.
I have read an understand the above policies and procedures that are in place and agree to the terms
that are defined.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original.

Patient/(Legal guardian) signature:

Printed name

Date

Ph: (403) 277-9339

Fx: (403) 277-2447

www.chiro-doctor.com

2713 Centre St NW
Calgary, AB T2E 2V5

CHIROPRACTIC

Health

C E N T R E
Electronic Transmission Authorization and Consent
Patient Name:
Benefits Provider:
Plan Member Name:
ID #:
Group/Policy/Contract #:
Service Provider:
Chiropractic Health Centre
Consent for Collection and Disclosure of Personal Information
Personal information that we collect in regards to extended health care is disclosed solely for the
purposes of determining eligibility and administering the benefits plan, this includes the investigation of
fraud and/or plan abuse.
Authorization for the Release of Information
I confirm that I, if not the plan member, am authorized by the individual to release any information
regarding them for the aforementioned purposes.
I permit Chiropractic Health Centre to collect, use, and disclose the necessary information needed in
the processing of my extended health care claims.
In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims
submitted I acknowledge and agree that my benefits provider and Chiropractic Health Centre may use and
disclose any relevant personal information to each other for the purpose of investigation and prevention of
fraud and/or plan abuse.
Assignment of Benefits
I agree to assign any benefits that are paid for my eligible claims to Chiropractic Health Centre and
authorize my benefits provider to issue payment directly to them. In the event any submitted claim(s) are
declined or only partially covered, I understand that I will remain responsible for the cost of the services
rendered. If any outstanding balances occur from this and legal action becomes necessary to collect on this
amount, I understand that I will be responsible for all attorney and legal fees incurred.
I understand the above terms and agree that this authorization is to apply to all eligible claim(s)
submitted electronically by Chiropractic Health Centre, and that I may revoke authorization at any time by
providing written notice.
I agree that a photocopy or electronic version of this authorization shall be as valid as the original,
and may remain in effect for the continued administration of the group benefits plan.

Patient/legal guardian signature

Printed name

Date
Ph: (403) 277-9339
Fx: (403) 277-2447

www.chiro-doctor.com
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2713 Centre St NW
Calgary, AB T2E 2V5