Please fill out our new patient form to help us better

understand your medical history and current needs.

This information will allow us to provide you

with the best possible care during your visit.

1. PATIENT INFORMATION

Date *

Patient Last Name *

Patient First Name *

Address *

Patient Email *

City *

State *

Zip Code *

Sex *

Male

Female

Date of birth

Patient/Employer School *

Occupation *

Employer/School Address *

Employer/School Phone *

Spouse's Name

Spouse's Employer

Spouse's Birthdate

Whom may we thank for referring you?

2. INSURANCE INFORMATION

Who is responsible for this account? *

Relationship to Patient *

Insurance Co.

Group# *

Is patient covered by additional insurance? *

Yes

No

Subscriber's Name *

Subscriber's Birth Date *

Subscriber's SS# *

Subscriber's Relation to Patient *

Subscriber's Insurance Co. *

Subscriber's Group # *

ASSIGNMENT AND RELEASE

I certify that I and/or my dependents(s), have insurance covered with

ASSIGNMENT AND RELEASE - Name of Insurance Company(ies) *

assign directly to

Doctor *

Signature of Patient, Parent, Guardian, or Personal Representative *

Clear

Please print name of Patient, Parent, Guardian, or Personal Representative *

Date Signed of Insurance Form *

Insurance Information - Relationship to Patient *

3. PHONE NUMBERS

Cellphone *

Homephone *

Best time and place to reach you *

IN CASE OF EMERGENCY, CONTACT

Emergency Contact Name *

Relationship *

Emergency Contact Cellphone *

Homephone *

Workphone *

Are you Pregnant? *

Yes

No

Due Date

Injuries/Surgeries you have had *

Falls
Head Injuries
Broken Bones
Dislocations
Surgeries

Medications/Allergies/Vitamins/Herbs/Minerals *

Medications
Allergies
Herbs/Minerals

Pharmacy Name

Pharmacy Phone Number

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT OF YOUR PAIN

The nature of chiropractic treatment: The doctor will use his hands or a mechanical device to manipulate the area treated. You may feel or hear a "click" or "pop" and you may fell movement. Chiropractic treatment also includes activity advice, exercise, hot or cold parks, or electric stimulation. Your chiropractor will recommend treatment he determines is most appropriate for your condition.

Possible risk: Chiropractic treatment for pain is sage and the majority of patients experience decreased pain and improved mobility. Approximately 30% of patients experience slight increased pain in the treated area, possible due to minor strain of muscle, tendon, or ligament. When his occur with exercise, heat, cold and electrical stimulation. Possible skin irritation or bums may occur with thermal or electrical therapy.

Serious bodily harm is extremely rare and not an inherent risk of chiropractic treatment. Many variables can adversely affect one's health, including previous injury, medications, osteoporosis, cancer and other illness or disease or condition. When these conditions are present, chiropractic treatment may be associated with serious adverse events, such as fracture, dislocation, or aggravation of previous injury to ligaments, intervertebral discs, nerves, or spinal cord. Symptoms of stroke or cerebrovascular injury alert patients to seek medical and/or chiropractic care. Your chiropractor is aware of this association and when appropriate may assess for symptoms and signs of stroke. Please inform your chiropractor of all medications you are taking, including blood thinners, any surgeries you have had, and any other medical condition you have, including osteoporosis, heart disease, cancer, stroke, fracture, or previous severe injury.

Other options for the treatment of pain include: do nothing-live with it, over-the-counter medications, physical therapy, medical care, injections, or surgery. There are hundreds of other treatments for pain. Most treatments that have potential benefit also have potential risk. You are encouraged to ask questions regarding possible risks of chiropractic treatment, and may use the space below for this purpose.

My signature below confirms that I have read the paragraphs above and that I understand what my chiropractor has told me about possible risk of chiropractic treatment and that I have had the opportunity to ask questions and have my questions answered. Also, I have fully disclosed to my chiropractor my medical history regarding the above specified complication factors and all other conditions that have cause me pain in the past.

Patient Signature *

Clear

Date: *

Witness Signature *

Clear

Witness Signature Date *

ASSIGNMENT AND INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR PRIVATE AND GROUP ACCIDENT AND HEALTH INSURANCE

Patient Name *

SS#/ID/# *

Employer

Claim/Group#

I hereby instruct and direct the

insurance company to pay by check made out to and mailed directly to:

Ringdahl Chiropractic Care, Inc.

David Ringdahl, D.C.

665 N. Tustin St. Suite L

Orange, CA 92867

If my current policy prohibits payment to doctor, then I hereby also instruct and direct you to make out the check to me and mail it as follows: C/O

For professional expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees over and above the insurance payments or as required by my insurance policy.

I also authorize the release of any information pertinent to my case to any insurance company, adjuster, or attorney involved in this claim.

Patient Signature *

Clear

Date *

Witness Signature *

Clear

Date *

CONSENT TO TREAT MINOR CHILD

I (Guardian Name)

,hereby authorize Dr. David Ringdahl, D.C. and whomever he may designate as his assistants to administer chiropractic care as deemed necessary to my (son/daughter/other)

Child name

Guardian Signature

Clear

Date

Witness Signature

Clear

Date