Patient Intake Forms

Patient Intake Forms

Patient Intake Forms

Patient Intake Forms

At Aktiv Integrative Chiropractic , we offer patient forms online so you can complete them in the convenience of your own home or office.​​​​​​​

Aktiv Integrative Chiropractic

5001 N. Mesa, Suite 2D

El Paso, Texas 79912

915.875.1494 o.

915.440.3056 f.

www.elpasoaktiv.com

PRIMARY INSURANCE INFORMATION (INFORMACION DE ASEGURANZA PRIMARIA)

SECONDARY INSURANCE INFORMATION (INFORMACION DE ASEGURANZA SECUNDARIA)

Please provide your insurance card and ID to the front desk.

The pain is described as? (El dolor es descrito como:)
Does the pain radiate? (El dolor irradia?)
The pain interferes with: (El dolor Interfiere con):
The pain is aggravated by: (El dolor es agravado por):
The pain is improved by: (El dolor es mejorado por):
Prior Treatments: (Tratamientos han incluido):
Please mark your area of pain. (Indique el area de dolor)
Scale: 0-10 0 = no pain, 10 = excruciating pain
(Escala de dolor: 0 - 10, 0 = No dolor 10 = dolor extremo)
Past Medical History (Historia Medica)
Surgical History (Historia de Cirugia)
Family History: (Historia Familiar)
Social History:
Historia Social

Marital Status (Estado Civil)
How much? Cuanto?
Alcohol:
Caffeine/Cafeina
Exercise/Ejercicio:
Water/Agua
Do you smoke? (Fumas?)
Recreational drugs? Uso recreativo de droga

Review of Symptoms (Sistema Medica)

Constitutional: (Estado Fisico)
HEENT: (Otorino)
Cardiology: (Cardiaco)
Respiratory: (Respiratorio)
Gastroenterology: (Gastrointestinal)
Female: (Sistema Femenino)
Male: (Sistema Masculino)
Urology: (Urologico)
Hematology: (Linfatico)
Endocrinology: (Endocrino)
Neurology: (Neurologico)
Dermatology: (Dermatologico)
Musculoskeletal: (Musculoesqueletico)
Psychology: (Psicologico)

Informed Consent to Treatment

I hereby request and consent to the performance of chiropractic techniques including various modes of physio-therapy, spinal adjustment, Active Release Technique, Graston Technique, massage therapy, and/or any other techniques deemed medically necessary on me (or on the patient named below, for whom I am legally responsible: ____________________________) by the chiropractic physician and/or anyone working in this office authorized by the chiropractic physician.

I further understand that such services may be performed and provided after thorough consultation, examination, and findings have been discussed and reviewed as well as all treatment options reviewed.

  

I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment; including, but not limited to: fractures, disc injuries, strokes (CVA), dislocations, and sprains. I do not expect the physician to be able to anticipate and explain all risks and complications. Some patients feel some stiffness and soreness. Following the first few days of treatment. The doctor 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 the doctor's attention. It is your responsibility to inform the doctor. Further, I wish to rely on the physician to exercise judgment during the course of the procedure which the physician feels are in my best interests at the time, based upon the facts then known.

  

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its contents, and by signing below, I agree to the treatment recommended by my physician. I intend this consent form to cover the entire course of treatment for my present condition(s) and for any condition(s) for which I seek treatment at this facility.

To be completed by the patient/To be completed by the patient's representative, if necessary, (e.g. if the patient is a minor or is physically or mentally incapacitated

Release of Medical Records Authorization (Autorizacion para Solicitar Registros Medicos)

I authorize the release of my records to include: (Autorizo los registros de)

 

o All Records (todos los registros)

o Patient Demographics (Informacion del paciente)

o Any and all Lab results (registros de laboratorio y patologia)

o Imaging and Radiology Reports (registros de radiologia / Rayos X)

o Billing Records (registros de facturacion)

 

Please fax records to: (por favor fax indicado registros para):

 

Aktiv Integrative Chiropractic

915-440-3056

 

Thank you for your help and cooperation in the patient's care.

(Gracias por su ayuda y cooperación en el cuidado de nuestros pacientes.)

PRACTICE FINANCIAL POLICY

Aktiv Integrative Chiropractic is dedicated to providing you with the best possible care and service. Your understanding of this practice's financial policies is an essential element of your care and treatment. If you have any questions, regarding this policy, please feel free to discuss them with our office administrator or Dr. Ponce. UNLESS OTHER ARRANGEMENTS HAVE BEEN MADE IN ADVANCE EITHER BY YOU, OR YOUR HEALTH INSURANCE CARRIER, FULL PAYMENT IS DUE AT THE TIME OF SERVICE. Cash, checks, credit cards and money orders are accepted.

INSURANCE

We have made prior arrangements with many insurers and health plans. We will bill those plans with whom we have an agreement and will collect any required copayment or deductibles at the time of service. In the event your health plan determines that the services are not covered, or has not paid the claim within 60 days, for any reason, you will be responsible for the total charges.

 

If you have insurance coverage with a plan with which we do not have prior arrangements, payments will be due at the time of service. We will prepare and send a claim to the insurance company for you, once that claim is paid only the copayment and deductible will be collected at the time of service for subsequent visit. Submission of claims to your insurance carrier will be completed by Millenium Medical Services (915) 532-0010.

MISSED APPOINTMENTS – NO SHOWS 

In order to provide the best possible service and availability to all our patients, it is our policy to charge an office visit fee of $20.00 for failure to cancel appointments with at least 24 hours notice

REFUNDS AND EXCHANGES

In the event services are not rendered at the discretion of Dr. Ponce and or the staff, a 100% refund will be made regardless of method of payment. 

 

With regard to retail product purchases, ALL SALES ARE FINAL. To ensure the integrity of products, NO REFUNDS OR EXCHANGES will be allowed if the product has been opened or product seal broken.

Co-Pays, Co-Insurance, Deductibles

All co-pays, co-insurance, and or anticipated deductible amounts will be charged prior to services rendered. In the event your insurance company pays more than anticipated, a refund will be issued to the patient within 30 days of insurance payment.

  

In the event you are left with an out of pocket balance to Aktiv Integrative Chiropractic, all payments must be made within 90 days of first statement date. Failure to pay within this time frame WILL RESULT in transfer of your account to a third party collection agency.

I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY OF THE PRACTICE, AND I AGREE TO BE BOUND BY ITS TERMS.

Thank you for taking the time to fill out this form.

admin none 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM 9:00 AM - 5:00 PM Closed Closed chiropractic # # #