Massage Patient Forms

1 PATIENT INFORMATION FORM

Full Name

Today's Date:

Social Security Number:

Birth Date:

Age:

Gender:

CURRENT ADDRESS

Street

City

State

Zip

Home Phone

Cell Phone

Your Occupation

Employer

Student at

FULL-TIME

PART-TIME

Marital Status:

Married

Separated

Widowed

Single

How many children?

Name of Spouse

Spouse's Date of Birth

Spouse's Occupation

Spouse's Employer

Spouse's Work Address

Work Phone

Spouse is a student at

FULL-TIME

PART-TIME

Who should we contact in the event of an emergency?

Phone

Address of contact person

How did you learn about us?

Referral

Search Engine

Yelp

Walk-in/Drive by

Print Advertisement

Website

Other

If you are under 18 years of age, who are your legal parents or guardian?

Father:

Phone:

Date of Birth:

Mother:

Phone:

Date of Birth:

Guardian / Foster Parent:

Phone:

Date of Birth:

Who do you normally live with (check all that apply)?

Father

Mother

Guardian / Foster Parent

Grandparent(s)

Brother(s) / Sister(s)

None of These

Did the condition or injury result from automobile accident?

If Yes, STOP HERE and click this link to go to Work or Auto Injury Patient Forms

Yes

Did it result from a work-related accident or cause?

Yes

If the condition did NOT result from an automobile accident or relate to your work, where did the accident occur?

Approximately, when did your injury or condition occur?

Describe your condition, symptoms, or the purpose of this appointment:

Have you ever had the same or similar condition?

Yes

Please indicate any other healthcare providers who you've seen for THIS injury or condition, and when you last saw them.

Name:

Type of Practice:

Date of Last Visit:

Name:

Type of Practice:

Date of Last Visit:

Name:

Type of Practice:

Date of Last Visit:

Date of last physical examination? :

What operations have you had?

When?

Serious illnesses or conditions?

Type

Date

Type

Date

Type

Date

Type

Date

Have you been treated for any health condition by a physician in the last year?

Yes

What medications or drugs are you taking?

Have you ever suffered from:

Dizziness

Arthritis

Digestive Disorders

Loss of strength arms/legs

Backaches

Headache/neck pain

Nervousness

Shortness of breath

Heart Trouble

Numbness

Sinus Trouble

Diabetes

Asthma

Anemia

Hernia (Disc)

Neuritis

Cancer

Other

WOMEN ONLY: Are you pregnant or is there any possibility you may be pregnant?

YES

UNCERTAIN

Do you have health insurance?

Yes

Insurance ID Number:

Group Number

Full Name of Policy Holder:

Policy Holder's Date of Birth:

Does the policy holder have the insurance through his/her employer?

Yes

I have read, understood and agree to the foregoing. The information which I have provided is true and complete to the best of my knowledge

Date:

Patient's Signature:

Clear

Oregon Spine and Disc - 5035 NE Elam Young Pkwy, Ste 300 - Hillsboro, OR 97124 - Tel: 503.626.3700 Fax 503.643.6667
Email: Frontdesk@OregonSpineandDisc.com Webpage www.OregonSpineandDisc.com
Dr. Kris Dearborn, Dr. Michael Ahn, Dr. Joseph Hamlin - Oregon Chiropractic Assoc. - English, Spanish, French and Korean spoken

2 Authorization to Disclose Medical Records

(Please Only Sign the Highlighted Box Below)

Patient Name:

Patient DOB:

Information to be released from:

Name of facility and/or provider:

City:

State

Phone:

Fax:

Information to be sent to:

Oregon Spine and Disc

5035 NE Elam Young Pkwy. Suite 300 Hillsboro, OR 97124

P.503-626-3700 F.503-643-6667

Purpose of disclosure:

The information will be used on my behalf for the following purpose:

Information to be released:

By initialing spaces below, I specifically authorize the release of the following medical records, if such records exist

Medical records needed for continuity of care

Most recent 5 year history

Laboratory reports

Clinician office chart notes

Pathology reports

Physical therapy records

Diagnostic Imaging

Billing records and statements

Other (please Specify)

Please send the entire medical record (all information) to the above name recipient.

Recipient understands this record may be voluminous and agrees to pay reasonable charges associated with providing records

HIV / Aids related records

Genetic testing information

Mental health information

Drug/Alcohol diagnosis, treatment, referral

*Must be initialed to be included in other documents.

Recipient understands this record may be voluminous and agrees to pay reasonable charges associated with providing records

This authorization is limited to the following treatment

This authorization is limited to the following time period

This authorization is limited to a worker’s compensation claim for injuries of

I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment or my eligibility for benefits.

This authorization may be revoked at any time. The only exception is when action has been taken in reliance on the authorization. Unless revoked earlier, this consent will expire 180 days from the date of signing or shall remain in effect for the period reasonably needed to complete the request

Patient Signature

Clear

Person Authorized by Law Signature

Clear

Date

3 Acknowledgement of receipt of Notice of Privacy Practice (HIPAA)

(Please Only Sign the Highlighted Box Below)

Regarding the Use & Disclosure of Protected Health Information

("Consent Form")

For the purposes of this Consent Form, “Office” shall refer to: Oregon Spine and Disc

I understand that some of my health information may be used and/or disclosed by the Office to carry out treatment, payment, or health care operations, and that for a more complete description of such uses and disclosures I should refer to the Office’s privacy notice entitled, “Our Privacy Practices.” I understand that I may review this privacy notice at any time prior signing this form.

I understand that over time the Office’s privacy practices may need to change in accordance with law and that if I wish to obtain a copy of the notice as revised, I can call the Office to request such copy

I understand that I may request restrictions on how my information is used or disclosed to carry out treatment, payment, or health care operations, and that I can also revoke this Consent in, but only to the extent that the Office has not taken action in reliance thereon and also provided that I do so in writing.

I understand that for my protection, any requests to amend my health information or to access my medical records must be made in writing.

I have also given authorization to (Person’s name and relationship to patient)

to access information to my account.

Patient Name (please print):

Date:

Signature:

Clear

"IF PATIENT IS A MINOR"(must be completed in person at the clinic)

Signature of Patient Representative
(Required if patient is a minor or adult unable to sign this form)

Clear

Date
.

Relationship to Patient

4 OREGON SPINE AND DISC FINANCIAL POLICY

(Please Only Sign the Highlighted Box Below)

CO-PAY IS DUE AT TIME OF SERVICE.
WE DO NOT SEND A BILL FOR YOUR CO-PAY.
WE DO NOT BILL YOUR SECONDARY INSURANCE BUT WE WILL BE HAPPY TO GIVE YOU A LEDGER FOR IT.
IT IS THE PATIENTS RESPONSIBILITY TO KNOW THEIR INSURANCE BENEFITS (YOUR CO-PAY OR DEDUCTABLE). WE WILL HELP YOU IN ANY WAY WE CAN BUT NOT ALL INFORMATION IS AVAILABLE TO US.
IF THE DEDUCTABLE HAS NOT BEEN MET, PATIENT IS RESPONSIBLE TO PAY IN FULL AT THE TIME OF SERVICE.
ANY SERVICE RENDERED, BUT NOT COVERED BY YOUR INSURANCE (ELECTRO-STIM, LASER, TRIGGER POINT OR MASSAGE, FOR EXAMPLE) IS DUE AT THE TIME OF SERVICE AT A DISCOUNTED FEE*.
WE DO NOT OFFER PAYMENT PLANS, BUT WE DO ACCEPT MAJOR CREDIT CARDS WITH NO FEES TO YOU.
IF THERE ARE ANY PATIENT BALANCES, OR INSURANCE ADJUSTMENT CREDITS, WE WILL NOTIFY YOU PROMPLY BY MAIL AND PHONE.

PLEASE NOTE: THE PATIENT IS ULTIMATELY RESPONSIBLE FOR ANY BALANCE NOT PAID BY INSURANCE.

*REMEMBER - WE OFFER GREAT DISCOUNTED " TIME OF SERVICE " (CASH) FEES FOR ANYONE WHO DOES NOT HAVE INSURANCE OR CHOOSES NOT TO USE THEIR INSURANCE.

THANK YOU, BILLING STAFF

I have read and understand the policy.

Signature

Clear

Date

*ChirohealthUSA.com is a discount medical plan which provides you and your family discounts on many services. They offer several plans which may include Chiropractic, Vision and Dental. Please go online or ask us for more information

5 FINANCIAL AGREEMENT

(Please Only Sign the Highlighted Box Below)

Please remember that insurance is considered a method to reimburse the patient for fees put to the doctor and it is NOT A SUBSTITUTE FOR PAYMENT. Some companies pay fixed allowances for certain procedures, and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance, or any other balance not paid by your insurance.

IN ORDER TO CONTROL YOUR OUTSTANDING BALANCE, IT IS OUR POLICY TO COLLECT CO-PAYS, COINSURANCE AND DEDUCTIBLE AT TIME OF SERVICE

If this account is assigned to an attorney/outside agency for collection an/or suit, Oregon Spine and Disc shall be entitled to reasonable attorney’s fees and for cost of collection.

I authorize the release of any information necessary to determine liability for payment and to obtain reimbursement on any claim.

Patient Signature

Clear

Date

LEGAL ASSIGNMENT OF BENEFITS AND RELEASE OF MEDICAL AND PLAN DOCUMENTS

In considering the amount of medical expenses to be incurred, I, the undersigned, have insurance and/or employee health care benefits coverage with the above captioned, and hereby assign and convey directly to Oregon Spine and Disc all medical benefits and/or insurance reimbursement, if any, otherwise payable to me for services rendered from such doctor and clinic. I understand that I am financially responsible for all charges regardless of any applicable insurance or benefit payments. I hereby authorize the doctor to release all medical information necessary to process this claim. I hereby authorize any plan administrator or fiduciary, insurer and my attorney to release to such doctor and clinic any and all plan documents, insurance policy an/or settlement information upon written request from such doctor and clinic in order to claim such medical benefits, reimbursement or any applicable remedies. I authorize the use of this signature on all my insurance and/or employee health benefits claim submissions

I hereby convey to the above named doctor and clinic to the full extent permissible under the law and under any applicable insurance policies and/or employee healthcare plan, any claim, chose in action, or other right I may have to such insurance and/or employee healthcare benefits coverage under any applicable insurance policies and/or employee healthcare plan with respect to any medical expenses incurred as a result of the medical services I received from the above named doctor and clinic and to the extent permissible under the law to claim such medical benefits, insurance reimbursement and any applicable remedies. Further, in response to any reasonable request for cooperation. I agree to cooperate with such doctor and clinic in any attempts by such doctor and clinic to pursue such claim, chose in action or right against my insurers and/or employee healthcare plan, including, if necessary, bring suit with such doctor and clinic against such insurers and/or employee healthcare plan in my name but at such doctor and clinic’s expenses

This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original. I have read and fully understand this agreement.

Signature (Insured or Guardian)

Clear

Date

Print Name

6 Informed Consent to Treat Self or Minor

Patient Name:

Patient Ins:

Patient DOB:

Patient ID:

The material risks inherent with Spinal Decompression: Certain complications may arise such as muscle spasm or increased pain. The spasm & pain is generally temporary and more common in the first weeks of beginning treatment. Please ask for copies of available studies.

The nature of the chiropractic manipulation: We may use our hands, an instrument, or both, to move the joints of your body; this may result in an audible "pop" or "click".

The material risks inherent in an adjustment: As with any healthcare procedure, certain complications may arise during a chiropractic manipulation. This may include: strains, dislocations, fractures, disc injuries and stroke. This list is not all inclusive.

The probability of those risks: Fractures are rare & can result from underlying weakness in the bones. Muscular strain (rare), ligamentous sprain (rare), fractures (rare), and injury to intervertebral discs, nerves or spinal cord (very rare), cerebrovascular injury, or stroke (very, very rare – chances are one in one million to one in ten million

Ancillary treatments recommended: Ice, Moist Heat Packs, Ultrasound, Electrical Muscle Stimulations, Stretching/Strengthening Exercises, Massage Therapy, Diathermy, Laser, Neuromuscular Re-education, Graston Technique and Decompression Spinal Traction

Risks involved with recommended ancillary treatments: Ice, Heat & Electrical Muscle Stimulations (EMS) can cause burning. EMS can cause skin irritation underneath active pads. Stretching/Strengthening Exercises & Decompression can cause muscle strains. This list is not all inclusive.

Other treatment options can include: Medical care, prescription drugs, self management with over-the-counter medication, rest, and/or surgery.

Medical care: Typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include numerous undesirable side effects, usually more serious than those listed above, and the patient dependence increases in a significant number of cases. The material risks include but not limited to: addiction to medication, side effects of medication and improper self dosages.

Surgery: In conjunction with medical care adds the risks of adverse reaction to anesthesia (which includes death) as well as an extended convalescent period in a significant number of cases

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility and possibly include chronic pain cycles. It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE

Patient name - Print

Date

Patient Signature

Clear

CONSENT TO TREAT MINOR - PLEASE FILL THE BELOW ONLY IF CONSENTING TO TREATMENT FOR A MINOR

I, the undersigned, attest that I am the custodial parent or legal guardian of the above-noted minor, and hereby authorize Oregon Spine and Disc to administer treatment as it so deems necessary to the minor. If the minor has received treatment at your practice previous to the date of this consent form, I hereby authorize such treatment in addition to the treatment mentioned above. I further authorize the minor to complete and sign any documents at Oregon Spine and Disc, which are customarily completed and signed by patients at your practice as a condition to treatment, and such signature shall serve as my own. In no event shall my signature to any other such document have any effect on this consent form. As of this date, I have the legal right to select and authorize health care services for the minor child named above

Date:

Relationship to patient:

Witness:

Print Name (Parent/Guardian):

Social Security (Parent/Guardian):

Signature:

Clear

7 Massage Informed Consent

Because a massage therapist must be aware of existing physical conditions I have stated all my known medical conditions and take it upon myself to keep the massage therapist update on my physical health. This massage is not a substitute for a medical exam and it is recommended that I see a physician for any physical ailments I might have. I understand that the massage therapist does not diagnose illness, disease or any other physical or mental disorder. The massage therapist prescribes neither medical treatment nor pharmaceuticals nor performs any spinal manipulations.

I understand that, although rare, side effects may result from massage therapy. These may include but are not limited to:minor muscle pain or tenderness that may last a few days, skin irritation from lotions, headache, bruising, and temporary aggravation of pre-existing conditions.
I’ve had an opportunity to discuss with the massage provider the nature, benefits and understand that results are not guaranteed. I understand that I may stop treatment at any time during the session.
I do not expect the massage provider to be able to anticipate all risks and complications. I wish to rely on the therapist to exercise judgment during treatment that the therapist feels are best, based upon the facts then known.
I understand that the massage therapy procedures and techniques used by the provider listed below are for therapeutic relief and stress management.
I understand that I can request a copy of this consent. 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.

If you are obviously ill (fever, cold symptoms, rashes, etc.) you will need to reschedule
Therapist may refuse service if at any time the massage appears inappropriate including sexual behavior (remarks or requests). Therapist or client has the right to end the session at any time.
You are liable for all services rendered and any balance that insurance does not pay or cover.
Please ask questions to thoroughly understand all aspects of the treatment.

Have you seen a doctor recently for anything?

Have you had any recent injuries or illnesses?

What would you like from your massage today?

Are there any areas you DO NOT WANT included in your massage?

Understanding all of this, I give my consent to receive care.

Signature

Clear

Print Name

Date

- Mark or Circle Areas Of Pain Or Discomfort -

Please check all that applies to you:

8 MASSAGE CANCELLATION POLICY

Although our Massage Therapist often have a waiting list of clients, No-Show or Last-Minute Cancellations greatly impact their scheduling.

Recognizing that we do set aside the scheduled time just for you, have other clients to consider, and have to maintain a smoothly running business, we now find it necessary to charge for:

NO-SHOW APPOINTMENTS

LAST MINUTE CANCELLATIONS

The Massage Therapists and Oregon Spine and Disc respectfully ask that you

Give a 24-hour notice of cancellation. Please Call 503-626-3700.

If we cannot answer, leave your information on our voice mail.

Sorry, cancellations made via email are not accepted.

- Prepaid appointments will be transferred to credit (minus No-Show fee) to be used at a later date.

- Appointments made within 24 hours are automatically subject to cancellation fees.

APPOINTMENT / CANCELLATION POLICY

CANCELATION FEE: $40.00

*First Last Minute Cancellation or No-Show is waived as a courtesy.

GIFT CERTIFICATES: Same policy applies.

LATE ARRIVAL: No fee is charged but your appointment will end at the scheduled time.

EMERGENCIES: We understand that emergencies and illnesses occur. If you have a fever, have been in the hospital, have been vomiting or diarrhea within 24 hours of your scheduled appointment, or your children are ill and need you at home, please cancel. Equally, if there is an ice storm, and you prefer not to drive or walk on the ice if you do not have to. Feel free to call and reschedule your appointment. There is NO CHARGE for these types of cancellations.

Other exceptions may apply.

PLEASE NOTE:
We will do our best to remind you of your appointment (we will send you a text) and we usually carry a waiting list of clients. Given enough notice, we can usually fill most appointments. Even if less than 24-hours of your appointment, please give us a much notice as possible and we will do our best to fill the appointment and avoid any cancelation fees.

If there’s simply no way of avoiding a short-notice cancellation, remember that you can send a friend or family member, or your boss or a client you need to earn points with to enjoy the massage!

Please Sign

Clear

Date

Thank you, Oregon Spine and Disc

Please Check and Complete Highlighted Fields Before Submitting

You will have a choice to print a copy for yourself at the end