Pediatric Patient Intake Form

PEDIATRIC HISTORY FORM

PATIENT DEMOGRAPHICS

Who should receive bills for payment on your account?
Would you like to receive reminder texts/emails for your appointments with us?
HOW DID YOU HEAR ABOUT US?

CHILD'S CURRENT PROBLEM:

Purpose of this visit*
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Ever had this problem before*
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How long ago?*
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How is this problem now?*
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Has your child ever suffered from:*
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Activities of Daily Living/Symptoms/Medications 

Daily Activities: Effects of Current Conditions on Performance:

Please identify how your current condition is affecting your ability to carry out activities that are routinely part of your life:

Bending*
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Doing computer Work*
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Concentrating*
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Playing Sports*
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Recreation Activities*
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Shoveling*
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Sleeping*
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Watching TV*
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Carrying*
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Dancing*
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Dressing*
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Lifting*
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Pushing*
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Rolling Over*
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Sitting*
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Standing*
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Climbing*
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Doing Chores*
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Driving*
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Reading*
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Running*
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Walking*
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Sitting to Standing*
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My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

ABOUT THE INSURED PERSON

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives. The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on behalf of. 

I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor's discretion.

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.*
Please select at least one option

Missed Appointments


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards/texts/emails are provided to help you save the date. If you need to re-schedule an appointment, please call/text our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a fee.

Patients needing to cancel an appointment MUST provide notice 24 HOURS prior to their appointment time. Failure to do so will result in a $25.00 cancellation fee.

No Call/No Show to any appointment will also result in a cancellation fee. 2 No Call/No Show visits will result in payment being required before any future appointments can be made. Cancellation fees are NOT covered by insurance.

If you have any questions or concerns regarding this policy please speak with our office or call (402) 421-1411.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.

If you do not have insurance or insurance does not cover a specific service provided to you at our office, payment is required at the time of service. If payment cannot be collected at time of service you may be asked to reschedule your appointment.

For your convenience, we accept cash, checks, Discover, MasterCard and Visa. Patients do have the option to pay for any services with an FSA, HSA, or HCA account/card.

If you have insurance, please provide the staff with the most current insurance card and we will file your primary and secondary insurance. Your insurance is a contract between you and your insurance company. You will be responsible for your account being paid in full either by you or your insurance company.

Co-pays, co-insurance and deductibles required by your insurance are your contractual obligation and will be collected up front or you may be asked to reschedule your appointment.

If you need to make monthly payments, a minimum of 20% of the balance is required each month. A finance charge of 1.5% per month is added to all overdue accounts. We do use a collection agency. If your account is sent to collections, your family care at our practice will be terminated. We realize that temporary financial problems may affect timely payment. Please contact the office with any special circumstances.



Authorization for Care:

I hereby request and consent to the performance of chiropractic adjustments, any other chiropractic procedures, including a comprehensive exam, X-rays, physical therapy techniques, acupuncture treatments, massage therapy, cupping therapy, and other Oriental Medicine procedures including various modes of physiotherapy on me.

I understand that, as with any health procedure, there are certain conditions that may arise during a chiropractic adjustment. Those complications include but are not limited to: fractures, dislocations, muscle strain, costovertebral strains and separations. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading to or contributing to serious complication including stroke. This is a very rare occurrence (a one in two to five million chance). We screen our patients for indications that they are candidates for chiropractic adjustments to the best of our ability.

I have been informed that acupuncture is a safe method of treatment, but that it may have side effects, including bruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. I understand that I should not make significant movements while the needles are being inserted, retained, or removed. Bruising is a common side effect. Unusual risks of acupuncture include spontaneous miscarriage, nerve damage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, although the acupuncturist uses sterile disposable needles and maintains a clean and safe environment. I understand that while this document describes the major risks of treatment other side effects and risks may occur.

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

AUTHORIZATION: I have read and agree to the above statements of Morgan Chiropractic & Acupuncture, PC. I understand that I am financially responsible for charges not covered or denied by my insurance and for all copay, co-insurance and deductible at the time of service. I authorize Morgan Chiropractic & Acupuncture, PC to release any medical information needed to process claims and authorize payment of benefits to be paid directly to Morgan Chiropractic & Acupuncture PC. I also agree to pay for the cost of collections, court cost, and other fees should they be required for nonpayment.


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

Sign Up Using the Form or Call Today for Your Free Consultation (402) 421-1411.

Office Hours

Our Regular Schedule

Monday:

9am-1pm

3pm-6pm

Tuesday:

9am-1pm

3pm-6pm

Wednesday:

9am-1pm

3pm-6pm

Thursday:

9am-1pm

3pm-6pm

Friday:

9:00 am-1:00 pm

Saturday:

Closed

Sunday:

Closed

Locations

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