Dr. Lindsey Jaccard, D.C.
Name _____________________________________________________ Date:_________________________
Mailing Address _______________________________City _______________ State ______ Zip ___________
Age __________ D.O.B. _____________ Married ___________ Single___________ #of Children _________
Occupation __________________________________ Employer ____________________________________
Home Phone __________________________________ Cell Phone __________________________________
Other Phone ___________________________________ E-Mail _____________________________________
Name of Nearest Relative: __________________________________ Phone #: ________________________
Referred to this office by: □ Family/ Friend - Name: ______________________________________
□Web Site □Mail □ Clinic Location □Other _______________________________________________
Please Answer any that apply within this box:
Yes I plan to submit payments to my insurance company for reimbursement. _________
Medicare # __________________________ Worker’s Compensation _____________________
Auto Medical Pay _____________________ Date of injury ____________
Liability (Other driver) __________________ Primary Insurance Provider ___________________
PAYMENT IS EXPECTED AT THE TIME OF VISIT
Name of Person responsible for payment _______________________________________________
Health and accident insurance policies are in arrangement between the carrier and the patient which are usually designed to offset a large portion of the total cost. This office will prepare any necessary reports and forms to assist in making collections from the insurance company to the patient, or any amount authorized to be paid directly to this office will be credited to the patient’s account. It should be understood that all services furnished are charged directly to the patient, who is personally responsible for payment. ALL SALES ARE FINAL
Patient Signature ____________________________________________ Date ________________________
Terms of Acceptance
When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain that goal. This will prevent any confusion or disappointment.
ADJUSTMENT: An adjustment is the specific application of force to facilitate the body’s correction of vertebral subluxations. Our Chiropractic method of correction is by specific adjustments of the spine.
HEALTH: A state of optimal physical, mental and social well being, not merely the absence of disease, infirmity or symptoms.
VERTEBRAL SUBLUXATION: A misalignment of one or more of the 24 vertebra in the spinal column which causes an alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.
We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.
Regardless of what disease is called, we do not offer to treat any disease. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.
I _______________________________________ have read and fully understand the above statements.
All Questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.
I therefore accept chiropractic care on this basis.
Consent to evaluate and adjust a minor child
I, __________________________________________________________ being the parent or legal guardian of
__________________________________________ have read and fully understand the above terms of acceptance and hereby grant permission for my child to receive chiropractic care.
This is to certify that to the best of my knowledge I am not pregnant and Dr. Lindsey Jaccard have my permission to perform x-ray evaluation. I have been advised that x-ray can be hazardous to an unborn child.
Date of last menstrual period: __________
Patient Signature & Date
Nutritional Informed Consent Form
According to the Federal Food, Drug, & Cosmetic Act, as amended,
Section 201 (g) (1), the term “DRUG” is defined to mean: “Articles intended for use in the Diagnosis, Cure, Mitigation, Treatment or Prevention of disease.”
A Vitamin is not a drug. NEITHER is a Mineral, Trace Element, Amino Acid, Herb or Homeopathic Remedy.
Although Vitamins, Minerals, Trace Elements, Amino Acids, or Herbs may have an effect on any disease process or symptom, this does not mean that it can be misrepresented or be classified as a drug by anyone.
Therefore, please be advised that any suggested nutritional advice or dietary advice is not intended as any primary treatment and/or therapy for any disease or particular bodily symptom.
Nutritional counseling, vitamin recommendations, nutritional advice, and the adjunctive schedule of nutrition is provided solely to upgrade the quality of food in the patient’s diet in order to supply good nutrition by supporting the physiological and bio-mechanical processes of the human body.
Nutritional advice and nutritional intake may also enhance the stabilization of the (8) chemical components of the VSC (vertebral Subluxation Complex).
At no point in time will Dr. Lindsey recommend a patient to come off their medication or go against the advice of their medical doctor. If a patient chooses that they do not want to continue a medication then they are strongly urged to discuss the matter with their medical doctor prior to discontinuing a medication. Stopping some medications without the help of a physician may lead to damaging long term effects.
I have read and understand to above information:
INFORMED CONSENT FOR ACUPUNCTURE
I hereby request and consent to the performance of acupuncture treatments and other procedures within the scope of the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by Dr. Lindsey Jaccard.
I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, acupressure, laser treatment of acupuncture points, and nutritional counseling.
I have been informed that acupuncture is a generally safe method of treatment, but that it may have some side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Bruising is a common side effect of cupping but can also be associated with needling. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the clinic uses sterile disposable needles and maintains a clean and safe environment. Burns and/or scarring are a potential risk of moxibustion. I understand that while this document describes the major risks of treatment, other side effects and risks may occur. I will notify Dr. Lindsey Jaccard if I am or do become pregnant to prevent potential risk of causing miscarriage.
I understand that results are not guaranteed.
By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, have been told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.
Are you currently Pregnant? YES NO
Patient Signature & Date
Please fill in the Following information:
Can our office leave a message with your home voice mail?_____________________________________
Can our office leave a message on your cell phone?____________________________________________
Is there any other person we can leave a message with if we are unable to reach you?
Name_________________________________ Contact Number_______________________________
Would you like to be reminded of appointments through:
_____Phone call Best number to reach you at: __________________________________________
_____Text message Cell Phone Number: _________________________________________________
_____E-mail Best E-mail address: ________________________________________________
E-mail address are not sold or shared. E-mail addresses are strictly used by the office for communication purposes.
Is there any way that our office may better serve you at this time? _________________________________
Patient Signature ____________________________________ Date ________________________________
Please list any prescription medications you are currently taking or have recently taken in the last year:
Please list any over-the-counter medications including vitamins, herbs or other substance you are taking:
Please List and Allergies you may have (medicine, food, environmental etc.)
1) Do you currently smoke or have you ever smoked? YES NO If yes what is your pack history?
2) Do you have a history of joint replacement? YES NO If Yes Please indicate what was replaced and on what side it was replaced? ____________________________________________________________________
3) Do you have a pace maker? YES NO
4) Do You have a history of Stroke or TIA (transient ischemic attack)? YES NO
5) Describe all serious accidents, severe injuries, head injury, fractures or broken bones (include date occurred): _________________________________________________________________________________
6) Is there a history of family violence? YES NO If yes Please indicate what type of abuse: PHYSICAL EMOTIONAL, SEXUAL OTHER _______________________________________________________________
7) DO you have a history of any of the following: (Please circle all that apply)
Measles, Mumps, Chickenpox, Whooping Cough, Scarlet Fever, Diphtheria, Smallpox, Pneumonia, Rheumatic Fever, Heart Disease, Arthritis, Venereal Disease, Anemia, Bladder Infections, Bone Fracture, Epilepsy, Migraine Headaches, Headaches, Nervousness/ Anxiety, Sinus trouble, Bowel problems, Multiple Sclerosis Indigestion, Tuberculosis, Rheumatism, Diabetes, Cancer, Polio, Glaucoma, Hernia, Blood or Plasma Transfusions, Back pain, Neck pain, High/low Blood Pressure, Hemorrhoids, Asthma, Hives/Eczema, AIDS or HIV, Dislocated joint, Reproductive Disorders, Numbness, Poor circulation, Chest pain, Concussion, Convulsions, Mono, Muscular Dystrophy, Asthma, Stroke, TIA, Car Accident,
8) Are you currently on anti-rejection medication due to organ transplant?__________________________
9) Are you currently on any immune suppressing medications due to illness?_______________________
10) Do you currently have a medically restricted diet or have you been told to avoid certain foods?__________
11) Do you have any religious or personal beliefs that restrict your diet?__________________
12) How much water do you drink in a day on average?_________________________________
13) Other than water what do you drink throughout the day and how much do you drink?___________________
14) What is your typical diet like in a day? How many times do you eat a day? __________________________
15) How frequently do you have a bowel movement on average? _____________________________________
16) Have you ever had Surgery? YES NO If yes then please explain: _______________________________
17) What brings you to the office today? ________________________________________________________
18) When did this problem start?______________________________________________________________
19) anything make it better?__________________________________________________________________
20) anything make it worse?__________________________________________________________________
21) Please list any other information that you feel is important for the doctor to know about you or this case:
The above information is true to the best of my knowledge.