New Patient Form

New Patients - Please Fill Out This Form

Personal Information

Name(Required)

First Last

Date of Birth (DOB)(Required)

Email(Required)

Phone(Required)

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Medical Information

Why are you coming in today?

Have you seen someone else for your Condition?

If you’ve seen another health care provider, what have they told you?

What are you hoping for out of todays visit?

How did you find us?

What medications, prescribed or over the counter, are you taking and why?

What supplements are you taking and why?

What surgeries have you had, when and what for?

Have you been in the hospital recently? If yes, what for?

Do you have any artificial joints, body parts, or hardware we need to be aware of? If yes, what?

Have you previously or currently been diagnosed with cancer? Y/N

Do you currently have an open workmans comp (work injury) or personal injury (car wreck) case anywhere? If so, with whom?

How’s your daily water intake? Please specify

How is your fruit and vegetable intake on a daily basis? (Circle one)

Great

Could be better

What are fruits and vegetables?

Anything else you’d like to tell us or think we should know?

INFORMED CONSENT

Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required by law to obtain your informed consent before starting treatment. I the undersigned, Do hereby give my consent to the performance of conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of manipulations/adjustments involving movement of the joints and soft tissues. Rehabilitative exercises may also be used. Although spinal and extremity manipulation/adjustment is considered to be one of the safest, most effective forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications associated with these procedures as follows: Soreness/Bruising: I am aware that, like exercise, it is common to experience muscle soreness and occasional bruising in the first few treatments. Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare. Fractures/Joint Injury: I further understand that in isolated cases, underlying physical defects, deformities or pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis, degenerative disc, or other abnormality is detected, this office will proceed with extra caution. Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are rare. I'm aware that nerve or brain damage including stroke is reported to occur 1-in-a-million to 1-in-10-million treatments. 1-in a million is about the same chance as getting hit by lightning. 1-in-10 million is about the same chance as a normal dose of aspirin or Tylenol causing death. Tests have been/will be performed to minimize risk of any complication from treatment. I freely assume these risks TREATMENT RESULTS I also understand that there are beneficial effects associated with these treatment procedures including: decreased pain, improved mobility/function, & reduced muscle spasm. However, I appreciate there is no certainty I will achieve these benefits. I realize that the practice of medicine, including chiropractic, is not an exact science and I acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the performance of these procedures by my doctor and such other individuals of the doctor's choosing. ALTERNATIVE TREATMENTS AVAILABLE Reasonable alternatives to these procedures have been explained to me including, rest, home applications of therapy, prescription or over-the-counter medications, exercises and possible surgery. Medications: Medication can be used to reduce pain or inflammation. I'm aware that long-term use or overuse of medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief, undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some medications may involve serious risks. Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may temporarily reduce inflammation and pain. The same is true of ice, heat or other home therapies and exercises. Prolonged bed rest contributes to weakened bones, joint stiffness and atrophy to muscles. Exercises are of limited value but are not corrective to injured nerve and joint tissues. Surgery: Surgery may be necessary for joint instability, pathology, or serious disc rupture. Surgical risks may include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery. Non-treatment: I understand potential risks of refusing/neglecting care may include: increased pain, scar/adhesion formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The aforementioned may complicate treatment, making future recovery & rehabilitation more difficult & lengthy. ----- I have read or had read to me the above explanation of chiropractic treatment. Any questions I have had regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT FORM. I have made my decision voluntarily and freely. ----- To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.(Required)

I agree to the terms below.

Medical doctors, chiropractic doctors, osteopaths, and physical therapists who perform manipulation are required
by law to obtain your informed consent before starting treatment.

I the undersigned, Do hereby give my consent to the performance of
conservative noninvasive treatment to the joints and soft tissues. I understand that the procedures may consist of
manipulations/adjustments involving movement of the joints and soft tissues. Rehabilitative exercises may also be
used. Although spinal and extremity manipulation/adjustment is considered to be one of the safest, most effective
forms of therapy for musculoskeletal problems, I am aware that there are possible risks and complications
associated with these procedures as follows:
Soreness/Bruising: I am aware that, like exercise, it is common to experience muscle soreness and occasional
bruising in the first few treatments.
Dizziness: Temporary symptoms like dizziness and nausea can occur but are relatively rare.
Fractures/Joint Injury: I further understand that in isolated cases, underlying physical defects, deformities or
pathologies like weak bones from osteoporosis may render the patient susceptible to injury. When osteoporosis,
degenerative disc, or other abnormality is detected, this office will proceed with extra caution.
Stroke: Although strokes happen with some frequency in our world, strokes from chiropractic adjustments are
rare. I'm aware that nerve or brain damage including stroke is reported to occur 1-in-a-million to 1-in-10-million
treatments. 1-in a million is about the same chance as getting hit by lightning. 1-in-10 million is about the same
chance as a normal dose of aspirin or Tylenol causing death.
Tests have been/will be performed to minimize risk of any complication from treatment. I freely assume these risks

TREATMENT RESULTS

I also understand that there are beneficial effects associated with these treatment procedures including: decreased
pain, improved mobility/function, & reduced muscle spasm. However, I appreciate there is no certainty I will
achieve these benefits. I realize that the practice of medicine, including chiropractic, is not an exact science and I
acknowledge that no guarantee has been made to me regarding the outcome of these procedures. I agree to the
performance of these procedures by my doctor and such other individuals of the doctor's choosing.

ALTERNATIVE TREATMENTS AVAILABLE

Reasonable alternatives to these procedures have been explained to me including, rest, home applications of
therapy, prescription or over-the-counter medications, exercises and possible surgery.
Medications: Medication can be used to reduce pain or inflammation. I'm aware that long-term use or overuse of
medication is always a cause for concern. Drugs may mask pathology, produce inadequate or short-term relief,
undesirable side effects, physical or psychological dependence, and may have to be continued indefinitely. Some
medications may involve serious risks.
Rest/Exercise: It has been explained to me that simple rest is not likely to reverse pathology, although it may
temporarily reduce inflammation and pain. The same is true of ice, heat or other home therapies and exercises.
Prolonged bed rest contributes to weakened bones, joint stiffness and atrophy to muscles. Exercises are of limited
value but are not corrective to injured nerve and joint tissues.
Surgery: Surgery may be necessary for joint instability, pathology, or serious disc rupture. Surgical risks may
include unsuccessful outcome, complications, pain or reaction to anesthesia, and prolonged recovery.
Non-treatment: I understand potential risks of refusing/neglecting care may include: increased pain, scar/adhesion
formation, restricted motion, possible nerve damage, increased inflammation, and worsening pathology. The
aforementioned may complicate treatment, making future recovery & rehabilitation more difficult & lengthy.
----- I have read or had read to me the above explanation of chiropractic treatment. Any questions I have had
regarding these procedures have been answered to my satisfaction PRIOR TO MY SIGNING THIS CONSENT
FORM. I have made my decision voluntarily and freely.
----- To attest to my consent to these procedures, I hereby affix my signature to this authorization for treatment.

Signature of Patient(Required)

Date(Required)

(if patient is a minor) Signature of Parent/Guardian

Date

Website and Social Media Release Form (Optional)

I agree to the terms below.

I, the undersigned, do hereby grant permission to KC Performance Chiropractic & Rehab
to post my and/or my child's story, photo, video, or other item, hereinafter for marketing,
social media, education, published article(s), audio, fundraising, promotion, website, printed
media, newspaper, and lecture on any current and future platforms and accounts held by KC
Performance Chiropractic & Rehab and their staff.

I hereby release you, your representative, employees, managers, members, officers, parent
companies, subsidiaries, and directors, from all claims and demands arising out of or in
connection with any use of said "Materials", including without limitation, all claims for invasion
of privacy, infringement of my right of publicity, defamation, and any other personal and/or
property rights.

I hereby release you, your representative, employees, managers, members, officers, parent
companies, subsidiaries, and directors, from all claims and demands arising out of or in
connection to myself, spouse, friend, acquaintance, or family member that may post private
information on any and all of KC Performance Chiropractic & Rehab’s social media platforms, or
other direct or indirect social media platforms that relate to KC Performance Chiropractic &
Rehab within any form or manner.

I acknowledge and agree that no sums whatsoever will be due to me as a result of the use
and/or exploitation of the "Materials" or any right therein.

I acknowledge that my child is under 18 years old and lacks the legal capacity to enter into
binding agreements. Accordingly, I have read this Release and consent to my child's inclusion in
the Materials will not contest the rights granted in this Release, and shall assist and support you
in any and all legal proceeding for affirmation of this Agreement, should you choose to have a
court of law affirm this Agreement.