RRUMCHIROPRACTIC

& Family Wellness

1318 S Jefferson. Mt. Pleasant, TX I 903.572.1128 | DurrumChiropractic.com

Welcome to Our Clinic!

Thank you for choosing our clinic for yourchiropractic care. We are committed to providingyou and your family with the highest quality ofchiropractic care available. We will be workingtogether toward helping you reach your health andwellness goals.

If you ever have any questions about yourchiropractic care, please don't hesitate to ask. All ofyour questions, even the ones you never thought ofasking, will most likely be answered during yourReport of Findings with the doctor. We look forwardto a long, healthy relationship with you and yourfamily.

OFFICE FEE SCHEDULE AND FINANCIAL POLICY

Financial Policy: We are committed to providing you the best chiropractic care possible in a caring

environment and have established our financial policies to achieve this goal. You will be expected to pay

for your chiropractic care at the time services are rendered unless other arrangements are made m

advance. Other arrangements include our bi-weekly, monthly & prepay Spinal Corrective Phase Plans.

The details of these plans will be discussed with you & all your questions will be answered at the time of

your Report of Findings (second scheduled visit).

Health insurance Policy: If you have insurance that covers chiropractic, we will give you a copy of the

necessary paperwork upon request so that you may submit a claim to your insurance provider for

reimbursement. It is your responsibility to send this information to your insurance provider. Your

insurance company will communicate with you about your reimbursement. Remember, your agreement

with the insurance company is between you and them, not us and them.

Medicare Policy: An ABN Option 1 is required with a signature before receiving care. Option 1 statesyou will only be reimbursed for 30 adjustments per calendar year from Medicare. After completion of

the 30 adjustments, you will then be required to sign an ABN Option 2 which states you still want to

receive care, but will not bill Medicare.

Service Normal Fees

New Patient visit $275

Adjustments $50

Progress exams $30

X-rays $30 per view

E-Stim $35.00

Ultrasound $10.00

Rehab (intersegmental table & Power Vibe) $30 per session

Fees and pricing structures are subject to a 196-2% increase at any time. You will be given 30 Day notice prior to

changes going into effect.

Payment InformationName of person responsible for payment: (print please).

I understand and agree that I am personally responsible for payment of all fees charged by this office for care. I

also understand that if I suspend or terminate care and treatment, any fees for professional services rendered or

any outstanding balance on equipment/supplements placed upon the account will be immediately due and

payable.

Dated the day of , 20

Signature (person responsible for payment)

Patient Signature (if different than person responsible for payment)

DurrumCHI ROPRACTIC

Name: (MI ) Nick Name: SS#:

Address: City: State: Zip: Age:

Home Phone: Cell Phone: ^Email: Date of Birth / /

Sex: □ M □ F Occupation: Employer: Work Phone:

Marital Status: DMOsnDnw

Next of Kin: Relationship:

Next of Kin Phone Number:

Who May we 'Thank" for referring you to our office?

Would you like to receive text message reminders of future appointment? Yes or No Ph #_

Why this form is important: As a full spectrum Chiropractic office, we focus on your ability to be healthy. Answeringthe following questions will give us a profile of the specific stresses you have faced in your lifetime, allowing us to betterassess the challenges you may face in regard to reaching your full health potential.

Past Chiropractic Care: Q Yes □ No This Year? Q Yes O No Previous chiropractor:What other wellness professionals are currently part of your healthcare team?^ Massage Therapist QAcupuncturist Q Other

List previous surgeries and dates:

List all Medications (prescription and over the counter^)

I I Pain Meds Q Anti-inflammatories □ Birth Control □ Heart Meds □ Cholesterol Meds □ OtherRepeated/Prolonged Antibiotic use?CII Yes Q No Inhaler Use? dlYes \Z\ NoWere you vaccinated? QYcs □ No Head Trauma? ^Yes Q NoFall/Jump from a height < 3 feet? QYes ONo Youth Sports? lUlYes □ NoFall/Jump from a height > 3 feet? QYes □ No Contact/Extreme Sports? QYes d No(i.e. crib, bunk bed, tree) Drug abuse? QYes Q NoSmoker? dYes d No Auto Accidents? dYes d NoAlcohol Consumption? dYes d NoOn a scale of 1 to 10 describe your stress level: (1 = None, 10= Extreme) Occupational: Personal:

Other Traumas? (Physical or Emotional)dYes d NoAs a child were you under regular Chiropractic Care? dYes d NoOn a scale of: Poor, Good or Excellent describe your:

Diet Exercise Sleep General Health

Rate your daily energy level: dHigh d Normal dLow d No energyAre there any other health concerns that we should be aware of? (MS, Diabetes, Chrons) dYes dNo

DurrumCHIROPRACTIC

Addressing the Issues That Brought You to Our Clinic

If you do not have any symptoms or complaints and are here for wellness care please check here. □Please briefly describe the chief area of complaint, including the effect it has had on your life.

Your Chief Complaint:

If you are experiencing pain, is it:

O Sharp QDuII Q Comes & goes □ Travels O Constant Other Q

When did this begin?

What makes it worse?

What makes it better?

_Since the problem started, is it: □ About the same Q Getting better □ Getting worse

Yes, it interferes with □ Work Q Sleep □ Walking DSitting nStairs nLifting □Hobbies.Other Doctors seen for this problem (Please List)

□ Chiropractor□ Medical Doctor

□ Other

□ Leisure

Health History Please check all the following health concerns that you have experienced, even if you do not think theyrelate to your present health condition

Anxiety □Yes □ No Asthma □Yes □ No

Depression □Yes □No Sinus Troubles □Yes □ No

Mood Swings □Yes □ No Allergies □Yes □ No

Arthritis □Yes □No Skin Conditions □Yes □ No

Osteoporosis □Yes □ No CirculatoryA^ascular Disease □Yes □ NoCancer □Yes □ No Heartburn/Acid Reflux / GERD □Yes □ NoImmune System Disorders □Yes □ No Kidney Disease □Yes □No

Heart Conditions □Yes □No Mid - Back Pain □Yes □NoNeck Pain □Yes □ No Low back Pain □Yes □No

Dizziness □Yes □ No Numbness/Tingling Legs □Yes □ No

Headaches □Yes □ No Diarrhea □Yes □ No

Numbness/Tingling armsor hands

□Yes □No Constipation □Yes □ No

Vertigo / Dizziness □Yes □No Bladder Problems □Yes □NoDifficulty Breathing Deeply □Yes □No Menstrual Cramps □Yes □NoHeart Palpitations □Yes □No Infertility □Yes □ NoDo you sleep well at night? □Yes □ No Are you well rested in the mornings? □Yes □No

CONSENT TO X-RAY

hereby authorize Dr. Durrum and whomever she designates as her assistants to take

X-rays of myself (or said minor). Date Signature.

PREGNANCY WARNING

I understand that if I am pregnant and have X-rays taken which could expose my lower torso to

radiation, it is possible to injure the fetus.

I have been advised that the 10 days following the onset of a menstrual period are generally

considered to be safe for X-ray examination.

With those factors in mind, 1 am advising my doctor that:

1 am pregnant: Yes No Don't Know

1 could be pregnant: Yes No Don't Know

1 have an lUD: Yes No Don't Know

1 have had a tubal llgation: Yes No Don't Know

1 am late with my menstrual period: Yes No Don't Know

1 am taking oral contraceptives: Yes No Don't Know

1 have had a hysterectomy: Yes No Don't Know

1 have irregular menstrual periods: Yes No Don't Know

My last menstrual period began on:

Patient Print Name: Patient's Signature:

Signature of Parent or Guardian (if patient is a minor)

CA Signature:

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.

The main goal of chiropractic is to correct vertebral subluxations of the spine. It is important that each patient

understand both this objective and the method we will use to attain it. This will prevent any confusion or

disappointment.

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 evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you

do desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health

care provider who specializes in that area.

Regardless of what the disease is called, we do not offer to treat it. 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 God-given ability to care for itself. Our only method is specific adjusting of the spine to correct vertebral

subluxations.l therefore accept chiropractic care on this basis.

(Signature) (Date)

DURRUM CHIROPRACTIC AND FAMILY WELLNESS

1318 S. Jefferson Ave

Mount Pleasant, Texas 75455

903-572-1128

Consent to use PHI

Acknowledgement for Consent to Use and Disclosure of Protected Health information

Your Protected Health Information will be used by Durrum Chiropractic and Family Wellness or

may be disclosed to others for the purposes of treatment, obtaining payment, or supporting theday-to-day health care operations of this office.

Notice of Privacy Practices

You should review the Notice of Patient Privacy Practices for a more complete description ofhow your Protected Health Information may be used or disclosed. It describes your rights as

they concern the limited use of health information, including your demographic information,collected from you and created or received by this office. I have received a copy of the Noticeof Patient Privacy Policy. Patient initials

Requesting a Restriction on the Use or Disclosure of Your Information

• You may request a restriction on the use or disclosure of your Protected HealthInformation.

• This office may or may not agree to restrict the use or disclosure of your Protected Health

Information.

• If we agree to your request, the restriction will be binding with this office. Use or

disclosure of protected information in violation of an agreed upon restriction will be a

violation of the federal privacy standards.

Revocation of Consent

You may revoke the consent to the use and disclosure of your Protected Health Information.

You must revoke this consent in writing. Any use or disclosure that has already occurred prior

to the date on which your revocation of consent is received will not be affected.

By my signature below I give my permission to use and disclose my health information.

Patient or Legally Authorized Individual Signature

Print Patient's Full Name

Witness Signature

DURRUM CHIROPRACTIC & FAMILY WELLNESS

Patient Authorization

Regarding "Open Adjusting" Environment

It Is the practice of this office to provide chiropractic care in an "open adjusting" environment. "Open

adjusting" involves 2 patients being seen in the same adjusting room at the same time. Patients are within

sight of one another and some ongoing routine details of care are discussed within earshot of other patients

and staff. This environment is used for ongoing care and is NOT the environment used for taking patient

histories, performing examinations or presenting reported findings. These procedures are completed in a

private, confidential setting. Patient may request and schedule a private consultation at anytime.

Your signature indicates your authorization of this activity.

Name (printed) Date

Authorization To Use Personal Health Information

I authorize Durrum Chiropractic to use any information needed, such as videos or written testimonials, for advertising

purposes on the following:

o YouTube

o Facebook

o Website

o E-mail

o All types of Health Talk Classes

(Print Name) (Signature)

(Date)