First Name Last Name Age: Male Female


Address: City: State: Zip:

SSN: Birth date:   Drivers License #:    Marital Status:

Home Phone:  Work Phone:    Other Phone:

Employer: Occupation: For How Long? yrs.

Nearest Relative:   Relationship: Phone:

Email address (for Patient Newsletter):

Reasons for your visit:
Have You Been Here Before?

Purpose of this appointment:

Reason for your visit is a result of: Work Injury Auto Accident Trauma Chronic Problem Other, describe here: Other:

Please describe the pain and its location:

Date of Injury/accident or when condition began:

Is Condition getting worse? Yes No Staying the same Comes and Goes Is this Condition Interfering with your: Work Sleep Daily Routine Other Other:

Have you been treated by another Doctor?   If Yes, please name doctor/health care facility:

Insurance Information:

Insurance Company:    Phone:   

Address:   City: State: Zip:

Name of insured:    SSN #: Insurance ID (if different from SSN #):    Insured's Birthday:

Policy/Group #: Plan Name: Relationship to you:

Insured's Employer:    Insurance Effective Date:

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Your Health History:

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Please list any medications you are taking, (including OTC): 

Please list any medications that you are allergic to:

Please list all surgeries and dates:

Medical Physician’s name:

Your Family History:
(some health problems are the result of familial tendencies)

If more than one sister or brother, please enter information here: 

Social History:

Do you smoke?  Yes No

Yes No If yes, how may packs per day? For how long? yrs.

Do you consume alcoholic beverages?   Yes No

If yes, select one: I drink Socially Moderately Daily Rarely

Do you exercise regularly?  Yes No

If yes, select one:  I exercise Daily Three Times a week Once a week Other, please specify      Other:

In the event of an emergency, who should we contact?  Relationship:
Emergency Contact Home Phone #:
Emergency Contact Work Phone #:

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Patient Health Information Consent Form
We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front desk before signing this consent.
1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance Company (or companies) provided to us by the patient for the purpose of payment. Be assured that this office will limit the release of all PHI to the minimum needed for what the insurance companies require for payment.
2. The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree to those restrictions.
3. A patient's written consent need only be obtained one time for all subsequent care given the patient in this office.
4. The patient may provide a written request to revoke consent at any time during care. This would not effect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.
5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a compliance officer has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.
6. Patients have the right to file a formal complaint with our compliance officer about any possible violations of these policies and procedures.
7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.

Informed Consent for Chiropractic Spinal Manipulation, Diagnostic X-Rays and Treatment, Authorization and Release
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of therapy modalities and diagnostic x-rays, on myself (or on the patient named below for whom I am legally responsible) by the licensed doctors of chiropractic of the Citrin Chiropractic Center or any doctor, who now or in the future, works as a relief doctor.

I have had the opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and other procedures and understand that spinal manipulation involves the doctor placing his or her hands on my spine and delivering a quick thrust or impulse to the involved area(s). I also understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains, soreness, and physical therapy burns. I understand and comprehend all such risks and complications. I, by my signature below, confirm and accept care and therefore consent to and agree to those treatments deemed necessary by my doctor to be in my best interest.

I authorize payment of insurance benefits directly to the Citrin Chiropractic Center. I understand and agree to allow this office to use my Confidential Patient Health Information forms for the purpose of treatment, payment, healthcare operations and coordination of care and authorize the Citrin Chiropractic Center to communicate with my medical physician(s) about my condition and treatment. I understand and agree that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand and agree that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

I understand the Federal Government has deemed it mandatory to notify my doctor of any other party or insurance company who may be responsible for reimbursement for my treatment.
I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.
I have also read, or have had read to me the above informed consent, authorization and release. I have had an opportunity to ask any and all questions about its content, and by signing below, I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for future condition(s) for which I seek treatment in this office.
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Patient Signature:                  Date:
Printed Name:

Consent to Treatment of a Minor Child:
I hereby authorize the doctors of the Citrin Chiropractic Center, and/or whomever they may designate as assistants,
to administer treatment as deemed necessary to: 
Name/Signature of Parent or Legal Guardian:   Relationship:

Date:      Witness signature/name:

CITRIN CHIROPRACTIC
Confidential Patient Health Information
10035 Page Blvd. St. Louis, MO. 63132 | phone: 314.890.2400 | fax: 314.890.2410
email: drc@citrinchiropractic.com

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