Forms

New Patient Forms

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GENERAL INFORMATION
Name*
First Middle Last
Address*
Street Address City State (Two-letter abbreviation) ZIP / Postal Code

Enter a zip code in the format XXXXX or XXXXX-XXXX
Phone (home)
Home Phone: U.S. phone numbers must be in (XXX) XXX-XXXX format (or add + for International Numbers)
Phone (work/cell)*
Cell Phone: U.S. phone numbers must be in (XXX) XXX-XXXX format (or add + for International Numbers)
Email*
Date of Birth*
Date Format: YYYY dash MM dash DD
Care of
No. Children
Spouse’s Name
Sex*
Status*

Patient's Employer or School
Employer or School Name
Employer or School Address
Street Address City State (Two-letter abbreviation)
Occupation
Student
Who may we thank for referring you

INSURANCE INFORMATION
COMMERCIAL INSURANCE AND MEDICARE ONLY
Primary Insurance Company
Are You Insured?*
- Yes
- No
Do you have an active health insurance plan?
Insurance Card (front)*
Please upload a picture of your insurance card
Insurance Card (back)*
Please upload a picture of your insurance card
Please upload your ID*
License or government issued ID card
Primary Insurance Name
(800) Phone #
Policy/Group #*
Member #*
Secondary Insurance Company
Secondary Insurance Name
(800) Phone #
Policy/Group #
Member #

POLICIES
I understand and agree that health and accident insurance policies are an arrangement between my insurance carrier and myself. Furthermore, I understand Scoliosis Systems LLP will prepare any necessary reports and forms to assist in making collections from my insurance company and that any amount authorized to be paid directly to New York Chiropractic Services will be credidted to my account upon receipt. However, I clearly understand and agree that all my serices rendered me are charged directly to me and I am personally responsible for payment.
Upload X-rays or Other Images - Front
Front View (AP)
Upload X-rays or Other Images - Side View
Side View (Lateral)
Doctor*
Date*
Date Format: MM slash DD slash YYYY
Guardian Signature Authorizing Care
If patient is a minor input your guardian name
Signature
Date
Date Format: MM slash DD slash YYYY
In case of emergency, notify:
Relationship
Address
Phone Number
Cell Phone: U.S. phone numbers must be in (XXX) XXX-XXXX format (or add + for International Numbers)
Patient Advisory and Notice of Privacy Practices*
I Agree to Patient Advisory To Consult A Physician and HIPAA
By checking this box you agree that you've received, reviewed and agree to the patient advisory and the HIPAA notice of privacy practices.
Signature*

INFORMED CONSENT

The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints. You may feel a "click" or "pop", such as the noise when a knuckle is "cracked", and you may feel movement of the joint. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used.

Possible Risks: As with any health care procedure, complications are possible following a chiropractic manipulation. Complications could include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke could occur upon severe injury to arteries of the neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. The ancillary procedures could produce skin irritation, burns or minor complications.

Probability of risks occurring: The risks of complications due to chiropractic treatment have been described as "rare", about as often as complications are seen from the taking of a single aspirin tablet. The risk of cerebrovascular injury or stroke, has been estimated at one in one million to one in twenty million, and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare".

Other treatment options which could be considered may include the following:

Over-the-counter analgesics. The risks of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.

Medical care, typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.

Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.

Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

Unusual risks: I have had the following unusual risks of my case explained to me.

I have read the explanation above of chiropractic treatment. I have had the opportunity to have any questions answered to my satisfaction. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided to undergo the recommended treatment, and herby give my full consent to treatment.
ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of Jaw before a jury, and instead are accepting the use of arbitration. Further, the parties will not have the right to participate as a member of any class of claimants, and there shall be no authority for any dispute to be decided on a class action basis. An arbitration can only decide a dispute between the parties and may not consolidate or join the claims of other persons who have similar claims.

Article 2: Al I Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the healthcare provider, induding any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving use to any claim. This agreement is intended to bind the patient and the healthcare provider and/or other licensed healthcare providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the healthcare provider, including those working at the healthcare provider's clinic or office or any other clinic or office whether signatories to this form or net

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the healthcare provider, and/or the healthcare provider's associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. This agreement is intended to create an open book account unless and until revoked.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) and provide National Arbitration and Mediation ("NAM") with the party arbitrator's contact information within thirty days of the date Respondent files its initial responsive pleading. A third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties from a list of arbitrators supplied by National Arbitration and Mediation ("NAlvr) within thirty days thereafter. The list supplied by NAM shall be a list of between 5 and 10 arbitrators, depending upon availability The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration Each party to the arbitration shall pay such party's equal share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party's own benefit Either party shall have the absolute right to bifurcate the issues of liability and damages upon written request to the neutral arbitrator

The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement The parties further agree that, where not in conflict with this agreement, the Healthcare Malpractice Dispute Resolution Rules and Procedures of NAM shall govern any arbitration conducted pursuant to this Arbitration Agreement A copy of NAM rules are available on its website at hftps://wimvnamadrcom or by calling 1-800-358-2550 to request a copy of the rules

Article 4: General Provision: All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding A claim shall be waived and forever barred if ('I ) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the healthcare provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment), patient should initial here Effective as of the date of first professional services

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Informed Consent and Arbitration Agreement.*
I have read and agree to the informed consent to treat and the arbitration agreement.
By law, we are required to provide you with informed consent. Please read and sign the informed consent to treat and the arbitration agreement.
Signature*

Insurance Verification Form Patient

Oswetry

New Patient Forms

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