Rochet Family Chiropractic New Patient Intake Forms
(561) 795-3156
Idioma / Language: English Español
1
Personal
2
Health History
3
Philosophy
4
Consents
5
Sign
Step 1 of 5

Personal Information

Please complete all fields accurately. This information is used for your health records and contact purposes only.

Patient Details
Family Members

If other family members will also be receiving care, please list them below.

Occupation & Emergency Contact
Insurance & Referral
Please complete all required fields before continuing.
Step 2 of 5

Health History

Please answer all questions as completely and accurately as possible. All information is confidential.

Reason for Today's Visit
X-Ray Authorization

Please read the following carefully and select your preference below.

I understand that:

  • → Dr. Rochet will be using the information he finds on the X-Rays of my spine to develop a Chiropractic care program for my specific situation.
  • → Dr. Rochet will not provide a chiropractic adjustment without X-Rays taken in this office, or in another medical office, within the last 3 months.
  • → This X-Ray examination may NOT be directly associated with where I currently experience symptoms.
  • → The taking of X-Rays carries risk (radiation), albeit minimal, and ALL X-Rays are taken at the Dr.'s discretion.
  • → I MUST schedule, within 7 days after my initial visit, my X-Ray report of findings / doctor's report, where I will receive explanation of my X-Ray findings, education as to the Chiropractic cause of my current condition, and recommendations for future Chiropractic care.
Past Health History
Have you ever seen a chiropractor before?
Have you had any spinal surgery?
Have you had any other surgeries?
Have you ever been in a motor vehicle accident?
Have you ever experienced a serious fall or injury?
Do you have any implants, pacemaker, or metal in your body?
Do you have osteoporosis or bone disease?
Are you currently taking any prescription medications?
Mental Health
Is stress a major problem for you?
Do you feel depressed?
Do you panic when stressed?
Do you have problems with eating or appetite?
Do you have trouble sleeping?
Have you ever been to a counselor?
Body Systems — Check Any Areas of Concern
Family Health History

For each family member, list their age and any significant health conditions.

MemberAgeM/FSignificant Health Conditions
Father
Mother
Sibling 1
Sibling 2
Maternal GM
Maternal GF
Paternal GM
Paternal GF
Is this form for a minor?
Please complete your reason for visit and select your X-Ray preference before continuing.
Step 3 of 5

Our Purpose

Please read the following statement carefully. It explains the foundational philosophy of care at Rochet Family Chiropractic.

A Statement of Clinical Objective

  • There IS intelligence — an Innate Intelligence — within us that not only keeps us alive, but also repairs, heals, animates and empowers us.
  • When the Nervous System flow is altered in function because of misalignment in the spine, this causes the Innate Intelligence to be blocked and inhibited.
  • Vertebral subluxations interfere with the proper functioning of the Nervous System.
  • The sole purpose of the Chiropractic Adjustment in this office is to reduce or correct the Vertebral Subluxation, with the intention of restoring the normal flow of the nerve impulse allowing the Nervous System to more effectively coordinate and control the body.
  • Everyone can benefit from a Nervous System which is FREE of Vertebral Subluxations.
  • Symptoms are NOT necessarily a sign of illness, but are manifestations of interference to the Nervous System and are used to alert the individual.
  • We DO NOT name or treat symptoms or conditions. Diagnosis is a MEDICAL act. Treatment is a MEDICAL act. We do not imply that getting adjusted will have a direct effect on any symptom or condition.
  • In this office, we locate and adjust Vertebral Subluxations in order to maximize each individual's expression of Life and Health.
  • In this office, we accept all cases regardless of condition or ability to pay.
Terms of Acceptance

Our office practices "Principled / Straight" Chiropractic care. Subluxation Based Care care has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it.

Adjustment / Correction: A Subluxation Based Care Adjustment, or correction, is the specific application of forces to facilitate the body's correction of a vertebral subluxation. Our method of correction is by specific adjustments to the spine, with specific attention paid to the upper cervical area.

Health: A state of optimal physical, mental, and social well-being, not merely the absence of disease, symptoms 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 its maximum health potential.

We do not offer to diagnose or treat any disease or condition. The only condition we address is the vertebral subluxation. However, if during the course of a spinal examination we encounter non-chiropractic or unusual findings, we will advise you.

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 adjustments to correct vertebral subluxations.

You must read and acknowledge the philosophy statement to continue.
Step 4 of 5

Consents & Authorizations

Please read each section carefully and check the box to indicate your agreement before continuing.

HIPAA — Patient Health Information Consent

We want you to know how your Patient Health Information (PHI) is going to be used in this office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form.

  1. The patient understands and agrees to allow this chiropractic office to use their Patient Health Information (PHI) for the purpose of treatment, payment, healthcare options, and coordination of care.
  2. The patient has the right to examine and obtain a copy of their own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI.
  3. A patient's written consent need only be obtained one time for all subsequent care given in this office.
  4. The patient may provide a written request to revoke consent at any time during care.
  5. For your security and right to privacy, all staff has been trained in the area of patient record privacy and a compliance officer has been designated to enforce those procedures.
  6. Patients have the right to file a formal complaint with our compliance officer about any possible violations of these policies and procedures.
  7. If the patient refuses to sign this consent for the purpose of treatment, payment and health care operations, the chiropractic physician has the right to refuse to give care.
Informed Consent for Chiropractic Care & X-Rays

I hereby request and consent to the performance of chiropractic adjustments, including diagnostic x-rays on myself (or on the patient named below for whom I am legally responsible) by the licensed Doctor of Rochet Family Chiropractic or any doctor who now or in the future works as a relief doctor.

I have had the opportunity to discuss with my doctor the nature and purpose of chiropractic adjustments and other procedures and understand that spinal adjusting involves the doctor placing his or her hands on my spine and delivering a quick thrust or impulse to the involved area(s).

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, spasms, and soreness. I understand and comprehend all such risks and complications.

I authorize payment of insurance benefits directly to Rochet Family Chiropractic. I understand and agree to allow this office to use my Confidential Patient Health Information for the purpose of treatment, payment, healthcare operations and coordination of care.

I understand and agree that I am responsible for all costs of chiropractic care, regardless of insurance coverage. I also understand and agree that if I suspend or terminate my schedule of care as determined by my treating doctor, any fees for professional services will be immediately due and payable.

I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment in this office.

Financial Responsibility
Please read and check all consent boxes above before continuing.
Step 5 of 5

Signature & Submit

Please sign below to complete your intake forms. Your signature confirms all information provided is accurate and that you agree to the consents reviewed in the previous step.

Submission Summary
Patient Signature

Sign in the box below using your finger (mobile) or mouse (desktop).

Sign above the line
Parent / Guardian Signature

Required for patients under 18.

Guardian signature
Please provide your printed name and signature before submitting.

Forms Submitted!

Thank you. Your new patient intake forms have been received by Rochet Family Chiropractic. Dr. Rochet's team will review your information before your first visit.

If you have any questions before your appointment, please call (561) 795-3156.

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