Welcome to Lobacz Chiropractic

 When a person seeks the services of a chiropractor, it is essential that they fully understand the objectives of that particular chiropractor.

We have one goal at Lobacz Chiropractic that is to restore and maintain the integrity of the spinal cord and its nerve roots. These vital nerve pathways are located in and protected by the bones of the spine. Misalignments of the vertebrae (bones of the spine), which interfere with the function of these nerve pathways, are called vertebral subluxations.  Subluxations are caused by many of the things you do everyday and keep your whole body from functioning properly. It is our absolute conviction that the body is always better off without this interference.

 

Consequently, the objective of Lobacz Chiropractic is to provide a chiropractic adjustment to correct subluxation thereby restoring normal nerve function. It is not the objective or intention of Lobacz Chiropractic to fix, treat or attempt to cure any physical, mental or emotional ailments or to give advice about any ailments. With a proper nerve supply your whole body is better able to reach its full potential and to express more life. 

The information we receive from you is important. We ask only that which is necessary for your care here at Lobacz Chiropractic. Please fill out the forms completely and to the best of your ability. If you have any questions or if there is any information you feel we should know, please mention it to the chiropractor.   Be aware, we do not furnish notes to insurance adjusters, disability handlers or insurance companies.  If you wish to try and receive reimbursement on your own for your care, that is fine, but we will not aid in the process by submitting any forms or documentation on your behalf, or to you. Also, any pictures taken when filling out this form is only for internal use, so we have a picture of you on file in our system.  When signing this agreement, our system will take a snapshot of the person signing the form.

 

 I have read the above, understand it fully, and choose to receive chiropractic for ourselves and our family members (listed below) on this basis.

Loading...

Lobacz Chiropractic New Patient Paperwork


Review Lobacz Chiropractic Privacy Policy

 

INFORMED CONSENT:

Every type of health care is associated with some risk of a potential problem. This includes chiropractic care.
We want you to be informed about potential problems associated with chiropractic health care before consenting to treatment. This is called informed consent.

In this office, we use trained assistants who may assist the physician with portions of your consultation,
examination, and rehabilitative therapies.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including but not limited to fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) f)or which I seek treatment.

Chiropractic is a system of health care delivery, and therefore, as with any health care delivery system, we
cannot promise a cure for any symptom, disease, or condition as a result of treatment in this clinic. We will
always provide you with the best care and if results are not acceptable, we will refer you to another health care provider who we feel may assist your condition.

If you have any questions on the above information, please ask your physician. Once you have a full
understanding, please sign and date below.

 

HIPPA:  

Use and Disclosure of your Protected Health Information

Your protected health information will be used by 
 or disclosed to others for the purposes of treatment, obtaining payment, or supporting the day-to-day health care operations of
this office.

Notice of Privacy Practices

You should review the Notice of Privacy Practices for a more complete description of how your protected health
information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office.
You may review the Notice prior to signing this consent.

Requesting a Restriction on the Use or Disclosure of Your Information

You may request a restriction on the use or disclosure of your protected health information. This office may or may not agree to your request to restrict the use or disclosure of your protected health information. If we agree to your request, the restriction will be binding with this office.

I have received a copy of  Lobacz Chiropractic's Notice of Privacy Practices.

First Patients Name

First Name*

Last Name*

Phone*
First Patients Date of Birth*
First Patients What brings you into the office today?
First Patients Signature*
Second Patients Name

First Name*

Last Name*
Second Patients Date of Birth*
Second Patients What brings you into the office today?
Third Patients Name

First Name*

Last Name*
Third Patients Date of Birth*
Third Patients What brings you into the office today?
Fourth Patients Name

First Name*

Last Name*
Fourth Patients Date of Birth*
Fourth Patients What brings you into the office today?
Fifth Patients Name

First Name*

Last Name*
Fifth Patients Date of Birth*
Fifth Patients What brings you into the office today?
Sixth Patients Name

First Name*

Last Name*
Sixth Patients Date of Birth*
Sixth Patients What brings you into the office today?
Seventh Patients Name

First Name*

Last Name*
Seventh Patients Date of Birth*
Seventh Patients What brings you into the office today?
Eighth Patients Name

First Name*

Last Name*
Eighth Patients Date of Birth*
Eighth Patients What brings you into the office today?
Ninth Patients Name

First Name*

Last Name*
Ninth Patients Date of Birth*
Ninth Patients What brings you into the office today?
Tenth Patients Name

First Name*

Last Name*
Tenth Patients Date of Birth*
Tenth Patients What brings you into the office today?
Patients Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
I would like to be placed on the mailing list
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
What else are you struggling with that you would like help with?

What else are you struggling with?
Have you been to a Chiropractor Before?
No
Yes
Have you had any surgeries on your spine? or anything the doctor should be aware of?
Are you interested in keeping your spine healthy with our membership program?
Click to customize multiple choice*
Yes
No
Maybe
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's What brings you into the office today?
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver