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To The New Patient Outline of Procedures For Care

Step One: All new patients are requested to fill out this personal health history questionnaire.

Step Two: A one-on-one consultation with the doctor will be done to discuss your health problems and to determine what may be the cause.

Step Three: A comprehensive examination and evaluation including those tests necessary to determined the precise cause of your problem is given.

Step Four: The doctors will advise you if additional laboratory tests or x-rays are needed.

Step Five: You will be given a Report of Findings at which time the cause of your problem will be discussed. It includes a thorough explanation of our treatment recommendations and what results can be obtained. You will also advised concerning how our office procedures work.

Step Six: If you are accepted as a patient, care will begin. Additional explanations will be given on the different types of treatments that are available in the office.

Step Seven: An estimate of the future care that is needed will be given and upon your acceptance, care will continue until the personal maximum correction of your problem has been obtained.

Step Eight: After maximum correction has been obtained, a schedule of care will be recommended to help prevent future problems and maintain good health.

Personal History

Current Health Condition

Past Health History

Below are a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.

Check Any Of The Following Diseases You Have Had:

Check Any Of The Following You Have Had The Past 6 Months:

Females Only:

Family History

The following members have a same or similar problem as I do:

Most patients that come to our office have one of two objectives in mind concerning their health care. Some patients come for symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program.

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary report and forms to assist me in making collection from the insurance company and that any amount authorized to be paid be directly to the Doctor's Office will be credited to my account on 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 suspect or terminate, any fees for professional services rendered me will be immediately due and payable.

I hereby authorized the Doctor to treat my condition as he or she deems appropriate. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and X-ray negatives will remain the property of the office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office.