PERSONAL INJURY QUESTIONNAIRE

Date of Accident: ________ / _________ / 20_______

Do you have a Police Report? Yes / No [Circle One]

If so, PLEASE PROVIDE COPY to our office.

Were you the: Driver or/ Passenger: [Circle One]

Were you wearing a seatbelt? Yes / No [Circle One]

Did the airbags deploy? Yes / No [Circle One]

Did you “see or sense” the accident was about to happen? Yes / No [Circle One]

Did you go to the ER? Yes / No [Circle One]

If so, where? ________________________________________________________________________

Were X-rays taken? Yes / No [Circle One]

Did you feel: Dizzy Nauseous Knocked Unconscious Tightness in the Chest

Have you had to take time off work? Yes / No [Circle One]

Are you represented by an Attorney or dealing directly with the Insurance Company?

[Circle One] Attorney / Insurance

Give A Short Summary of Accident: ____________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

INFORMED CONSENT FORM

Patient Name: ______________________________________ Date: _______ / _______ / 20_______

TO THE PATIENT: Please read this entire document prior to signing it. It is important that you fully understand the information contained in this document. If anything is unclear, please as our office staff before you sign it.

The Nature of the Chiropractic Adjustment:The primary treatment I use as a Doctor of Chiropractic is spinal manipulative therapy. I will use that procedure to treat you. I may use my hands or a mechanical instrument upon your body in such a way as to move your joints. That may cause an audible “pop” or “click,” much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.

Analysis / Examination / Treatment:As a part of the analysis, examination, and treatment, you are consenting to the following procedures:

X spinal manipulative therapy X palpation X vital signsX range of motion testing X orthopedic testing X basic neurological testX muscle strength testing X postural analysis X Electrical StimX radiographic studies X mechanical tractionX Other (* see below)

*Manual Therapy & Therapeutic Stretching

The Material Risk Inherent in a Chiropractic Adjustment: As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to my attention, it is your responsibility to inform me.

The Probability of Those Risks Occurring: Fractures are rare occurrences and generally result from some underlying weakness of the bone which I check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke are exceedingly rare and are estimated to occur between one in one million and one in five million cervical adjustments. The other complications are also generally described as rare.

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

INFORMED CONSENT FORM

The Availability and Nature of Other Treatment Options: Other treatment options for your condition may include:

• Self-administered, over-the-counter analgesics and rest

• Medical care / prescription drugs such as anti-inflammatory, muscle relaxants and pain-killers

• Hospitalization

• Surgery

If you chose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of such options and you may wish to discuss these with your primary medical physician.

The Risks and Dangers Attendant to Remaining Untreated: Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE. PLEASE CHECK THE APPROPRIATE BLOCK AND SIGN BELOW

I have read [ ] or have had read to me [ ] the above explanation of the chiropractic adjustment and related treatment. I have discussed it with ( Dr. Denman or Staff ) and have had my questions answered to my satisfaction. By signing below I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the treatment recommended. Having been informed of the risks, I hereby give my consent to that treatment.

Dated: _____ /_____/ 20____ Dated: _____ /_____/ 20____

_____________________________ Derrick W. Denman D.C., PA______ Patient’s Name Doctor’s Name

_____________________________ _______________________________ Signature Signature

_____________________________ Signature of Parent or Guardian (if a minor)

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575

TEL: 704.735.8226 FAX: 704.735.8280

LIEN/ BENEFITS ASSIGNED

To Whom it May Concern,

I hereby authorize and direct you; the insurance company with coverage applicable to my claim(s) and to any attorney representing me, make payments directly to:

LINCOLN CHIROPRACTIC DR. DERRICK W. DENMAN D.C., PA

P.O. BOX 575 LINCOLNTON, NC 28093-0575 Tax ID: 56-2117051

Such sums as may be due and owing this office for services rendered me, both by reason of accident or illness, and by reason of any other bills that are due Lincoln Chiropractic and to withhold such sums from any disability benefits, medical payments, no-fault benefits, health and accident benefits, workmen’s compensation benefits, or any other insurance benefits obligated to reimburse me or from any settlement, judgement or verdict on my behalf as may be necessary to adequately protect said office.

I hereby further give a lien to said office against any and all insurance benefits named herein, and any and all proceeds of any settlement, judgement or verdict which may be paid as a result of the injuries or illness for which I have been treated by said office. This is to act as an assignment of my rights and benefits to the extent office’s services provided.

In the event my insurance company obligated to make payments to me upon the charges made by this office, for their services, refuses to make such payments, upon demand by me or this office, I hereby assign and transfer to this office any and all causes of action that might have or that might exist in my favor against such company and authorize this office to prosecute said cause of action either in my name or in the office’s name and furthermore, I authorize this office to compromise, settle or otherwise resolve said claim or cause of action as they see fit.

I understand that I remain personally responsible for the total amounts due Lincoln Chiropractic for their services. I further understand and agree that this assignment, lien or authorization does not constitute and consideration for the office await payments and they may demand payments from me immediately upon rendering services at their potion.

I authorize Lincoln Chiropractic to release any information pertinent to my case to any insurance company, adjuster or attorney to facilitate collection under their assignment, lien and authorization. I agree the above mentioned office be given power of attorney to endorse/sign my name on any and all checks for payment of my doctor bill.

Signature: ___________________________________________ Date: _______ / _______ / 20____ Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

MED-PAY BENEFITS FORM

Many patients we encounter have MED-PAY benefits included in their auto-insurance policies, and don’t even realize it. If you have Med-Pay, our office highly recommends that you use your coverage, regardless of who is at fault in the automobile accident.

Here are six [ 6 ] reasons why we recommend filing your Med-Pay:

1. Increase Your Settlement- You are more likely to obtain a much higher settlement with Med-Pay coverage.

2. Reduces Out-of-Pocket Expenses- Even if you are at fault, Med-Pay Benefits cover reasonable and necessary medical expenses, up to your limit coverage.

3. Med-Pay is Similar to Health Insurance- Using your Med-Pay does NOT cause your rates to increase.

4. Filing Your Med-Pay Doesn’t Relieve the Other Party from Having to Pay in full for Your Loss- On the contrary, by filing your Med-Pay, when you collect from the other driver’s Liability Insurance, a greater amount of the settlement will go directly to you because your bill at Lincoln Chiropractic may be paid in full.

5. Med-Pay Provides Protection- If the other driver’s Liability Insurance refuses to make payment to you for whatever reason, filing your Med-Pay will help insure that you are not stuck with all the medical bills.

6. Med-Pay is a Benefit- Filing your Med-Pay is common sense. It is a benefit option you are already paying for.

The important fact to remember is that you are not guaranteed of receiving full payment from the other driver’s Liability Insurance Company. Filing your Med-Pay will help you insure that you are not left paying the medical bills. If Lincoln Chiropractic receives an OVER-PAYMENT on your account, we will be prompt in refunding you the difference.

Signature: ___________________________________________ Date: _______ / _______ / 20_____

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

ATTORNEY/ INSURANCE INFORMATION

Attorney / Case Worker’s Name: ________________________________________________

Attorney / Case Worker’s Contact Number: __________ - _________ - ________________

Vehicle Insurance Company [ Responsible for Medical Bills ]:

______________________________________________________________________________

Adjuster’s Name: ______________________________________________________________

Adjuster’s Contact Number: ___________ - ___________ - _____________________

Fax Number: ___________ - ___________ - ____________________

Adjuster’s Email Address: ______________________________________________ . _______

Claim Number: ________________________________________________________________

Do you have Med-Pay? Yes / No [Circle One]

Med-Pay Claim Number: __________________________

Med-Pay Amount: ________________________________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Any failure to provide the above information will unfortunately result in the delay of necessary treatment. The purpose of this form is to assume liability of Lincoln Chiropractic charges. If the above information is not obtained in a timely manner, you will be responsible for any/all outstanding bills.

If the patient is under 18, the parent or guardian must sign below:

Patient Name: _______________________________________________________________________

Signature: __________________________________________Date: _______ / _______ / 20______

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

RELEASE OF MEDICAL RECORDS

Name: ___________________________ DOB:____/_____/_______ SS:_________________________

I hereby authorize Lincoln Chiropractic to: ____ release of medical records to (specific person/ organization and address below) OR ____ obtain medical records from (specific person/ organization and address below)

Name:_________________________________Address: _____________________________________Name:_________________________________Address: _____________________________________Name:_________________________________Address: _____________________________________Name:_________________________________ Address: _____________________________________

Information to be disclosed: (Please check the appropriate box or boxes below)

Date(s) of Service: __________ to _______________ Entire Record___ Doctor’s Notes___ Radiology Reports___ Health History ___ Consultation Results

Purpose of disclosure: The above information is released for the following and that purpose only. Any other disclosure is prohibited without my specific written authorization.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

I hereby acknowledge this authorization is voluntary and is valid until such request is fulfilled but not to exceed 6 months from the date signed. I release, discharge and agree to hold harmless all parties to whom this authorization is given from any liability that may arise from the release of information authorized above. I may revoke this request, in writing at any time except to the extent that action based on this authorization has taken place. I understand that a photocopy of facsimile transmission of this authorization is considered acceptable in lieu of the original. I understand I do not need to sign this form in order to ensure health care treatment, payment, enrollment in my health plan, or eligibility for benefits. I also understand that if the organization authorized to receive the information is not a health plan or a health care provider, the release information may be disclosed by the recipient and may no longer be protected by federal privacy regulations.

____________________________________ _____________________________________Signature of Patient or Authorized Legal Representative Relationship of Authorized Representative to Patient

_________________________________________________ ____________________________________________Date Time AM / PM Witness (employee is acceptable)

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280

X-RAY CONSENT FORM

Todays Date: ________ / _________ / 20_______

THIS FORM VERIFIES THAT:

_____ To the best of my knowledge I am not pregnant or believe there is any possibility

that I may be pregnant.

_____ I know or believe that I may be pregnant and fully understand the risk and health effects

radiation may cause to my unborn baby.

_____ I give my full consent to have x-rays taken by Lincoln Chiropractic: Chronic

Conditions & Wellness Center.

Patient: ________________________________________________

Signature: _______________________________________________

WITNESS: _______________________________________________

Derrick W Denman D.C., PA dba/ Lincoln Chiropractic: Chronic Conditions & Wellness Center 108 Newbold St. Lincolnton NC 28092 / P.O. Box 575 Lincolnton NC 28093-0575 TEL: 704.735.8226 FAX: 704.735.8280