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Location

Renaissance Chiropractic Center

Address
4902 Tacoma Mall Blvd.,
,
Tacoma, WA 98409 US

Phone
253-473-0300

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Welcome To Our Practice

New Patients

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New Patient Intake

New Patient Intake

Let us get started filling out this form.

I understand this is a legal agreement and Intend to sign,
I also Agree to sign this agreement electronically.
Terms of consent

Renaissance Chiropractic Center

4902 Tacoma Mall Blvd., Tacoma, WA 98409 (253) 473-0300

First Name*

Last Name*

Preferred Name

Sex*

Please select one option

Mailing Address*

Apt #

City*

State/Province*

Please select one option

Zip Code*

Home Phone

Cell Phone*

Work Phone

Email*

General Health Insurance:

Ins Co*

Subscriber*

ID#*

May we contact you at work?*

Please select one option

Yes

SS #*

Birthdate*

Age*

Occupation*

Employer*

Employer's Address*

Marital Status*

Please select one option

Married

Single

Divorced

Widowed

Spouse's Name*

Birthdate*

Spouse's SS #

Minor Children's Names & Ages

Emergency Contact*

Relationship*

Phone #'s*

How did you find out about our office?*

Please select at least one option

Insurance Company

Doctor

Our Website

Internet

Friend/Family

Other

If Friend/Family member, then please tell us who referred you so we can thank them

If Other, please describe

What brings you here? Please check one*

Please select one option

General Health

Work Injury

Auto Accident

Other Accident

How long have you had these concerns?*

Is it*

Please select one option

getting worse

improving

staying the same

Where is the problem? (part of your body)*

Please explain injury (if applicable)*

When did the incident occur?*

Have you been off work for this injury*

Please select one option

Yes

For how long? If this does not apply, please write N/A*

If you have been off work, who took you off work? If this does not apply, please write N/A*

Have you received Chiropractic before?*

Please select one option

Yes

If yes, please tell us the doctor's name

Were you pleased with your care?

Yes

If no, please explain

Are you currently receiving care from other health professionals for these complaints ?*

Please select one option

Yes

Who is your Primary Care Physician (PCP)?*

Do you take any medications?*

Please select one option

Yes

If yes, for what conditions?

Do you take vitamins/herbs/homeopathics?*

Please select one option

Yes

If yes, do you take them for a specific condition?

Ladies:

Are you pregnant?

Yes

If yes, what month are you due?

Date of last menstrual cycle

Health History

Please check all of the following that you currently suffering with:*

Please select at least one option

Headache

Migraines

Frequent Nausea

Constipation

Neck Pain

Dental Problems

Irritable Bowel

Fatigue

Middle Back Pain

Jaw Pain

Excessive Thirst

Bloody Stools

Lower Back Pain

Vision Problems

Vomiting

Hemorrhoids

Shoulder Pain

Difficulty Breathing

Prostate Problems

Liver Problems

Arm Pain or Tingling

Stuffy Nose

Breast Pain or Lump

Stroke

Hand Pain

Allergies

Cramps

Paralysis

Leg Pain or Tingling

Fainting

Painful Urination

Tingling

Foot Pain or Tingling

Weight Loss or Gain

Bladder Problems

Numbness

Chest Pain

Poor Appetite

Excessive Urination

Cold Extremities

Infectious or Contagious disease

Auto or Work Injury

Head Injuries

Fights

Falls or Accidents

Dislocations

Spinal Tap

Surgery

Broken Bones

Use a Walker or Cane

Extensive Dental Work

Excessive Alcohol use

Sports Injuries

Knocked Unconscious

Diabetes

Smoking

Other

If Other, please describe

Please list any Surgeries you have had

What Do You Know About Chiropractic?

In your own words, what do chiropractors do?*

Do you know what spinal nerve stress/subluxation is?*

Please select one option

Yes

If yes, please describe

What would you like to gain from chiropractic care?*

Do you have friends/relatives who see chiropractors?*

Please select one option

Yes

If yes, do they use chiropractic for:*

Please select one option

health maintenance/optimization

health problems

both

Are you seeking chiropractic for*

Please select one option

health maintenance/optimization

health problems

both

Please read through each paragraph.

Acknowledgement of Receipt of Notice of Privacy Practices:

RENAISSANCE CHIROPRACTIC CENTER USES PERSONAL INFORMATION ONLY AS RELATED TO PROVIDING CARE AND BILLING PURPOSES IN ACCORDANCE WITH STATE AND FEDERAL PRIVACY GUIDELINES. WE DO NOT SHARE YOUR INFORMATION BEYOND WHAT IS REQUIRED FOR THESE PURPOSES. I acknowledge that I may request a copy of the Notice of Privacy Practices or I have declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.

Financial Responsibility:

I hereby state that the information on this form is true and correct. I authorize Renaissance Chiropractic Center to examine, take x-rays (if necessary), treat me, and do whatever they deem necessary in accordance with the state statutes, for the care and management of my condition. I understand and agree that health and insurance policies are an arrangement between an insurance carrier and myself. I also understand that Renaissance Chiropractic Center will prepare any necessary reports and forms to assist me in making collection from the insurance company, and that any amount authorized to be paid directly to Renaissance Chiropractic Center will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for services rendered me will be immediately due and payable. Your account will be assessed a $35.00 cancellation fee if our office is not contacted 24 hours prior to your scheduled appointment. Insurance benefits are based on a "Good faith" quote from your insurance company. However, this is not a guarantee of payment.

Terms of Acceptance:

When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustment of the spine.

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.

Vertebral subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express it's maximum health potential.

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

I (Name),*

have read and fully understand the above statements.

All questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis.

Signature*

Date Signed*

Printed Name*

Email*

I, parent/guardian, give permission for minor's care

Informed Consent to Care

You are the decision-maker for your health care. Part of our role is to provide you with information to assist you in making informed choices. This process is often referred to as "informed consent" and involves your understanding and agreement regarding the care we recommend, the benefits and risks associated with the care, alternatives, and the potential effect on your health if you choose not to receive the care.

We may conduct some diagnostic or examination procedures if indicated. Any examinations or tests conducted will be carefully performed but may be uncomfortable.

Chiropractic care centrally involves what is known as a chiropractic adjustment. There may be additional supportive procedures or recommendations as well. When providing an adjustment, we use our hands or an instrument to reposition anatomical structures, such as vertebrae. Potential benefits of an adjustment include restoring normal joint motion, reducing swelling and inflammation in a joint, reducing pain in the joint, and improving neurological functioning and overall well-being.

It is important that you understand, as with all health care approaches, results are not guaranteed, and there is not a promise to cure. As with all types of healthcare interventions, there are some risks to care, including, but not limited to: muscle spasms, aggravating and/or temporary increase in symptoms, lack of improvement of symptoms, fractures (broken bones), disk injuries, strokes, dislocations, strains, and sprains. With respect to strokes, there is a rare but serious condition known as "arterial dissection" that typically is caused by a tear in the inner layer of the artery that may cause the development of a thrombus (clot) with the potential to lead to stroke. The best available scientific evidence supports the understanding that chiropractic adjustment does not cause a dissection in a normal, healthy artery. Disease processes, genetic disorders, medications, and vessel abnormalities may cause an artery to be more susceptible to dissection. Strokes caused by arterial dissections have been associated with over 72 everyday activities such as sneezing, driving, and playing tennis.

Arterial dissections occur in 3-4 of every 100,000 people whether they are receiving health care or not. Patients who experience this condition often, but not always, present to their medical doctor or chiropractor with neck pain and headaches. Unfortunately, a percentage of these patients will experience a stroke.

The reported association between chiropractic visits and stroke is exceedingly rare and is estimated to be related in one in one million to one in two million cervical adjustments. For comparison, the incidence of hospital admission attributed to aspirin use from major GI events of the entire (upper and lower) GI tract was 1219 events per one million persons per year and the risk of death has been estimated as 104 per one million users.

It is also important that you understand there are treatment options available for your condition other than chiropractic procedures. Likely, you have tried many of these approaches already. These options may include, but are not limited to: self-administered care, over-the-counter pain relievers, physical measures and rest, medical care with prescription drugs, physical therapy, bracing, injections, and surgery. Lastly, you have the right to a second opinion and to secure other opinions about your circumstances and health care as you see fit.

I (Name)*

have read, or have had read to me, the above consent. I appreciate that it is not possible to consider every possible complication to care. I have also had an opportunity to ask questions about its content and, by signing below, I agree with the current or future recommendation to receive chiropractic care as is deemed appropriate for my circumstance. I intend this consent to cover the entire course of care from all providers in this office for my present condition and for any future condition(s) for which I seek chiropractic care from this office.

Signature*

Date Signed*

Printed Name*

Email*

Auto Accident Questionnaire

Date of Accident*

Please Write A Detailed Description Of The Accident:*

If auto accident, were you*

Please select one option

driver

passenger

pedestrian

Location:

City*

State*

Street(s)*

Road Conditions*

Please select one option

Dry

Wet

Icy

Other

If Other, please describe

What kind of vehicle were you in?*

What type of transmission in your vehicle:*

Please select one option

Automatic

Manual (stick-shift)

Were you aware of the impending collision or were you surprised?*

Please select one option

Aware

Surprised

Were you struck from:*

Please select one option

behind

right side

left side

front

Did the other car strike yours?*

Please select one option

Yes

Did your car strike the others involved?*

Please select one option

Yes

Were there multiple impacts?*

Please select one option

Yes

If yes, how many

Was your foot on the brake?*

Please select one option

Yes

Were you wearing your seatbelt?*

Please select one option

Yes

Did any Airbags deploy?*

Please select at least one option

Yes

front

side curtain

At the impact was your head facing:*

Please select one option

forward

to the right

to the left

Other

If Other, please describe

How was the headrest positioned for your head?*

Please select one option

high

low

middle

no head rest

After the collision, what direction was your vehicle facing*

Please select one option

same

to the right

to the left

facing the opposite direction

not sure

other

If Other, please describe

What was the other vehicle?*

Was there more than one other vehicle involved:*

Please select one option

Yes

how many?*

What kind?*

Did the impact cause you to lose your glasses or hat?*

Please select one option

Yes

Did you hit any part of the body on anything inside the vehicle?*

Please select one option

Yes

what?

Did you lose consciousness?*

Please select one option

Yes

Were you treated by the Paramedics at the scene?*

Please select one option

Yes

Were you taken by ambulance to the hospital emergency room?*

Please select one option

Yes

Did you have x-rays taken?*

Please select one option

Yes

What regions?

Were you given any medications?*

Please select one option

Yes

What?

Condition since Accident:*

Please select one option

Worsened

Improved

Stayed the same

PLEASE CHECK SYMPTOMS YOU HAVE NOTICED SINCE THE ACCIDENT:*

Please select at least one option

Headaches

Dizziness

Light Bothers Eyes

Diarrhea

Neck Pain

Head Seems Too Heavy

Loss of Memory

Constipation

Neck Stiffness

Pins and Needles in Arm

Ears Ringing

Stomach Upset

Upper Back Pain

Pins and Needles in Legs

Face Flushed

Hands Cold

Middle Back Pain

Numbness in Fingers

Buzzing in Ears

Feet Cold

Lower Back Pain

Numbness in Toes

Loss of Balance

Cold Sweats

Anxiety

Shortness of Breath

Loss of Smell

Fever

Irritability

Fatigue

Loss of Taste

Chest Pain

Depression

Sleeping Problems

Other

Have you been involved in any prior motor vehicle collisions*

Please select one option

Yes

Patient's Auto Insurance:

Do you have Personal Injury Protection (PIP)*

Please select one option

Yes

Company Name*

Phone #*

Address

Claim #*

Claim Manager's name*

Auto Insurance Company Responsible in Accident:

Company Name*

Phone #*

Claim #*

Claim Manager's name*

Address

Name of person responsible for accident*

Name of insured on this policy

Do you have an attorney involved in this case?*

Please select one option

Yes

If so, attorney's name

Phone #

I understand that interest will be charged on any unpaid balance due on my account commencing on the first day of my being released from active/scheduled treatment. Interest on my account shall be at the rate of twelve percent (12%) per annum on the balance owed by me and will be calculated half-yearly from date of my release from active/scheduled treatment and every six (6) months thereafter.

Signature*

Date Signed*

Printed Name*

Email*

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

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

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Renaissance Chiropractic Center

Address

4902 Tacoma Mall Blvd.,
Tacoma, WA 98409

Phone

253-473-0300

Contact Us

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Phone *

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Monday

9:00am - 12:30pm

2:00pm - 6:00pm

Tuesday

9:00am - 1:00 pm

3:00pm - 7:00pm

Wednesday

9:00am - 12:30pm

2:00pm - 6:00pm

Thursday

9:00am - 1:00 pm

3:00pm - 7:00pm

Friday

9:00am - 12:30pm

2:00pm - 6:00pm

Saturday

9:00am - 12:00pm

Sunday

Closed

4902 Tacoma Mall Blvd.

Tacoma, WA 98409

253-473-0300

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