Did your vehicle impact another vehicle? Yes No Is there visible damage to the car? Yes No If yes, briefly explain: Did your vehicle impact a structure? Yes No If yes, briefly explain: Did any part of your body strike anything in the vehicle? Yes No If yes, what/where: Was impact from: Front Rear Right Other At the time of impact were you: Looking straight ahead Looking right Looking left Looking up Looking downWere both hands on the steering wheel? Yes No If no, was one hand on the steering wheel? Yes NoWas your foot on the brake? Yes No If yes, which foot? Were you: Surprised Braced for impact

Patient Name: Email: Address: City: State: Zip: Home Phone: Cell: Work: Preferred # Home Cell WorkEmergency Contact Name: Emergency Contact Phone: Attorney Name: Attorney Phone: Date of Birth: Age: SS# Sex: Male Female Married Widowed Single Minor Separated Divorced PartneredOccupation: Employer/School: Phone: Whom may we thank for referring you?

Motor Vehicle Accident Intake PATIENT INFORMATION

ACCIDENT INFORMATIONDate of Accident: Time of Accident: How many people were in the vehicle? Road/Street Name: City/State: Nearest Intersection: Which direction were you heading? Driving Conditions Dry Wet Icy Other What speed were you traveling? Please describe the accident in your own words:

IMPACT INFORMATION

Place an X where the impact(s) occurred

Make and Model of vehicle you were in: Were you wearing a seatbelt? Yes NoIf yes, what type? Lap ShoulderDid the vehicle have airbags? Yes No If yes, did they inflate properly? Yes NoDid your seat have a headrest? Yes NoWere you at work at the time? Yes NoOther people in the car (Full proper name and relationship to you):

VEHICLE 1 INFORMATION (The vehicle you were in) VEHICLE 1 INSURANCE INFORMATION (MANDATORY)

Were you the: Driver Front Passenger Rear Passenger PedestrianWas the vehicle you were in at fault? Yes No

Driver’s Name: Is the insured the same as the driver? Yes No If no, name of insured: Make & Model of other vehicle: Which direction was the other vehicle heading? How fast was the other vehicle going?

OTHER VEHICLE INFORMATION/3rd party

*It doesn’t matter who is at fault, we need the insurance information for the vehicle you were in.* This is required in order for D’Vida to bill under a motor vehicle accident claim. Insurance Company Name: Claim Number: Adjuster’s Name: Adjuster’s Phone: Ext. Have you opened a medical claim? Yes NoDid your insurance send you a PIP Application? Yes NoIf so, have you returned it to them? Yes No

OTHER AUTO INSURANCE INFORMATIONThird Party Insurance Co. Name: Claim # for other vehicle: Adjuster’s Name: Adjuster’s Phone: Ext.

POLICE INFORMATION

Did police come to accident? Yes NoWere there any witnesses? Yes NoWas a police report filed? Yes NoWas a traffic violation issued? Yes No If yes, to whom:

MEDICAL HISTORY

HIV/AIDS

Alcohol ism

Al lergy Shots

Anemia

Anorex ia

Apendic i t is

Arthr i t is

As thma

Bleeding Disorders

Breast Lump

Bronchi t is

Bul imia

Cancer

Cataracts

Chemica l Dependency

Chicken Pox

Diabetes

Emphysema

Epi lepsy

Fractures

Glaucoma

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Goi ter

Gonorrea

Gout

Hear t Disease

Hepat i t is

Hern ia

Herniated Disc

Herpes

High Blood Pressure

High Cholestero l

Kidney Disease

Liver Disease

Measles

Migra ine Headaches

Miscarr iage

Mononucleos is

Mul t ip le Sc leros is

Mumps

Osteoporos is

Pacemaker

Park inson 's Disease

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

Pinched Nerve

Pneumonia

Pol io

Prostate Problem

Prosthes is

Psychiat r ic Care

Rheumato id Ar thr i t is

Rheumat ic Fever

Scar le t Fever

Sexual ly Transmi t ted Disease

Stroke

Suic ide At tempt

Tonsi l i t is

Thyro id Problems

Tubercu los is

Tumors, Growths

Typhoid Fever

Ulcers

Vagina l In fect ions

Whooping Cough

Other :

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

No

EXERCISE WORK ACTIVITY HABITS

None

Moderate

Daily

Heavy

Smoking

Alcohol

Coffee/Caffiene

______Packs/Day

______Drinks/Weeks

______Cups/Day

High Stress ______________________ Reason

Are you pregnant? Yes No Date of delivery: ____________________

Injuries you've had: Description Date

____________________________________________________________ __________________

____________________________________________________________ __________________

____________________________________________________________ __________________

Falls

Head Injuries

Broken Bones

Dislocations

Surgeries

____________________________________________________________ __________________

____________________________________________________________ __________________

Medication Allergies Vitamins/Supplements

Pharmacy: _______________________

Pharmacy Phone: ______________

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

O

____________________________________________

____________________________________________

____________________________________________

____________________________________________

____________________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

__________________________________________

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

NoO OYes

None

Moderate

Daily

Heavy

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibi l ity toinform my doctor if I , or my minor child, ever have a change in health.

Signature of patient, parent, guardian, or personal representative Date

Please print name of patient, parent, guardian, or personal representative Relationship to patient

Were you unconscious immediately after the accident? If yes, for how long?

Please describe how you felt immediately after the accident:

PATIENT CONDITION

Did you go to the hospital? How did you get there? Ambulance Private Vehicle

When did you go? Immediately after the accident Next day 2 or more days later

Name of Hospital: Name of Doctor:

Diagnosis:

X-Rays taken:

HOSPITAL

Have you treated anywhere elsewhere for this injury?

If yes, type of treatment(s):

Start date of treatment: Last treatment date:

Name of doctor: Name of Facil ity:

OTHER TREATMENT

Have you been able to work since the injury? How many days missed?

Prior to the injury were you able to work on an equal basis to others of your age?

If you have any of the fol lowing symptoms/injuries since the accident, please check:

Is this condition(s) getting: Better Worse The same Unknown

Type of Pain:

Sleep Daily Routine Recreation

How often do you have this pain ?

Is it constant or does it come and go?Does i t interfere with your: Work Movements that are painful to perform:

SYMPTOMS/INJURIES

Arm/Shoulder Pain

Back Pain

Chest Pain

Dizziness

Ear Buzzing

Ear Ringing

Fatigue

Feet/Toe numbness

Hand/Finger numbness

Headaches

Irritabil ity

Jaw problems

Leg pain

Memory loss

Neck pain

Neck stiff

Shortness of breath

Sleep difficulty

Stomach upset

Tension

Vision blurred

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibi l ity toinform my doctor if I , or my minor child, ever have a change in health.

Signature of patient, parent, guardian, or personal representative Date

Please print name of patient, parent, guardian, or personal representative Relationship to patient

Yes No

Yes No

Yes No

Yes No

Yes No

Circle your pain level

Sl ight 1 2 3 4 5 6 7 8 9 1 0 Severe

Sharp

Aching

Cramps

Dull

Shooting

Stiffness

Throbbing

Burning

Swell ing

Numbness

Tingl ing

Other: __________

Sitting

Bending

Standing

Lying Down

Walking

Mark an X anywhere you have pain,

numbness or tingl ing

HIPAA Patient Consent Form

We are required by the health insurance portability and accountability act of 1996 (HIPAA) to maintain the privacy ofyour protected health information (PHI) and to provide you with a notice of privacy practices. Our notice of privacypractices provides information about how we may use and disclose your PHI, and contains a section describing yourrights as a patient under the law. You have the right to review our notice before signing this consent and you areadvised to do so.

By signing this form, you consent to our use and disclosure to third parties of your PHI for treatment, payment,healthcare operations and for certain marketing purposes, as described in our Notice of Privacy Practices. If you signthis Consent but later change your mind, you have the right to revoke this Consent by delivering to us a written, dateddocument signed by you. However, such a revocation shall not affect any disclosures we have already made inreliance on your prior consent.

The patient understands that:

• The clinic has a Notice of Privacy Practices. The patient has received, and had the opportunity to review, this Notice before signingthe consent. The Clinic encourages all patients to review the Notice of Privacy Practices.

• The Clinic reserves the right to modify the Notice of Privacy Practices to keep up with changes in the law or office practices. We willmake all modifications available for review by patients.

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations

• The Clinic or its business affiliates may use your PHI to contact you with educational and promotional items in the future via email,U.S. Mail, telephone, fax and/or prerecorded messages. We WILL NOT ever sell or “SPAM” your personal contact information.

• The patient has the right to restrict the uses of his or her information, but the Clinic does not have to agree to all such restrictions.

• The patient may revoke this Consent in writing at any time and all future disclosures that require the patient's prior written consentwill then cease.

• The Clinic may condition receipt of treatment upon the execution of this consent.

The Consent was signed by:Printed Name - Patient or Representative

Signature Date

Relationship to Patient(if other than patient)

Witness:Printed Name - Clinic Representative

Signature Date

Consent for Chiropractic Treatment

Chiropractic examination and therapeutic procedures (including spinal adjustments, ultrasound, heat application,electrotherapy and manual muscle therapy) are considered safe and effective methods of care. Occasionally, however,complications may arise. Any procedure intended to help may have complications. While the chances of experiencingcomplications are small, it is the practice of this clinic to inform our patients about them. Side effects include but are notlimited to, soreness, inflammation, soft tissue injury, dizziness, burns, and temporary worsening of symptoms. More seriouscomplications are extremely rare and their association with spinal adjustments (manipulation) is debated. Thesecomplications include injury to the arteries in the neck which may be associated with stroke and serious neurologicimpairment, injuries to the spinal discs, and spinal fractures. Serious complications are estimated to be in range of .5- 2incidents per million adjustments for adjustments of the neck, and 1 per million for adjustments of the lower back. Additionalinformation on side-effects, complications and effectiveness of spinal adjustments is available upon request.

I have read and understand that the above statements regarding treatment side-effects. I also understand that there is noguarantee or warranty for a specific cure or result.

Patient Signature: Date:

Consent for Massage Therapy

I (Please print Name) understand the following:

• A massage therapist does not diagnose illness or disease, or any other disorder.• Massage therapy is not a substitute for Medical Examination or medical care, and is recommended that I am

currently working with my primary caregiver for any condition I may have.• The relationship between the client and the therapist is a confidential one and that all information provided to the

therapist will be kept confidential.• My body will be draped at all times for comfort, security and warmth.• I have right to request and require that any procedure or technique be modified, changed or stopped.• I have the right to have any part of my body not massaged (please let the therapist know).• The massage therapist is a licensed professional and has the right to terminate session under the circumstances where

I use unwanted, harmful or offensive language or behavior.• I have stated all my known physical conditions, medical conditions, and medications. I will keep my massage

therapist updated on any changes.• I will inform the therapist of any discomfort, so the application of pressure or strokes may be adjusted accordingly to

fit my level of comfort.• By signing this form, I also give consent for future sessions. I have read this form and hereby freely give my

permission to be massaged.

As a minor, I have been informed in the presence of my guardian.

Patient Signature: Date:

Therapist Signature: Date:

Consent for Acupuncture Therapy

I hereby request and consent to the performance of acupuncture treatments and other procedures within the scopeof the practice of acupuncture on me (or on the patient named below, for whom I am legally responsible) by theacupuncturist indicated below and/or other licensed acupuncturists who now or in the future treat me whileemployed by, working or associated with or serving as back-up for the acupuncturist named below, including thoseworking at the clinic or office listed below or any other office or clinic, whether signatories to this form or not.

I understand that methods of treatment may include, but are not limited to, acupuncture, moxibustion, cupping,electrical stimulation, Tui-Na (Chinese massage), Chinese herbal medicine, and nutritional counseling. I have beeninformed that acupuncture is a generally safe method of treatment, but that it may have some side effects, includingbruising, numbness or tingling near the needling sites that may last a few days, and dizziness or fainting. Burnsand/or scarring are a potential risk of moxibustion and cupping, or when treatment involves the use of heat lamps.Bruising is a common side effect of cupping. Unusual risks of acupuncture include spontaneous miscarriage, nervedamage and organ puncture, including lung puncture (pneumothorax). Infection is another possible risk, althoughthe clinic uses sterile disposable needles and maintains a clean and safe environment.

I understand that while this document describes the major risks of treatment, other side effects and risks may occur.I understand that all my records will be kept confidential and will not be released without my written consent.

By voluntarily signing below, I show that I have read, or have had read to me, the above consent to treatment, havebeen told about the risks and benefits of acupuncture and other procedures, and have had an opportunity to askquestions. I intend this consent form to cover the entire course of treatment for my present condition and for anyfuture condition(s) for which I seek treatment.

Acupuncturist Name:

Patient Signature: Date:(Or Patient Representative- Indicate relationship if signing for patient)

Authorization For Release of Medical Record Information

Patient Name: _____________________________ Date of Birth: __________________

Phone: H) ________________________ Phone: C) _________________________

Address: ________________________________ City, State, Zip: __________________________________Please Note: Copy Fee May Be Charged For Medical Records

Above listed patient authorizes the following healthcare facility to make record disclosure:

Facility Name:_____________________________ Facility Phone: ______________________Facility Address: Facility Fax:____________________ City, State, Zip: _________________________________________

I understand the information in my health record may include information relating to sexually transmitted disease, acquireimmunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioralor mental health services, and treatment for alcohol or drug abuse.

By initialing the spaces below, I specifically authorize the release of the following information, to D'Vida Injury Clinic and Wellness Center.____ Medical Records _____ Lab Reports / Pathology Reports_____ Diagnostic Imaging Reports _____ Emergency/ Urgency Care Records, Hospital records_____ Billing Statements _____ Other:__________________________________

This information may be disclosed and used by the following individual or organization:

Release To: D'Vida Injury Clinic & Wellness CenterAddress, City, State, Zip:3835 SW 185th Avenue Ste 400, Beaverton, OR 97078 Fax: (503) 641-6665 Phone: (503) 626-2166

I understand I may revoke this authorization at any time. I understand that if I revoke this authorization I must do so in writing andpresent my written revocation to the health information management department. I understand that the revocation will not apply toinformation that has already been released in response to this authorization. I understand that the revocation will not apply to myinsurance company when the law provides my insurer with the right to contest a claim under my policy.

I understand that authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I need notsign this form in order to assure treatment. I understand that I may inspect or obtain a copy of the information to be used ordisclosed. I understand that any disclosure of information carries with it the potential for an unauthorized re disclosure and theinformation may not be protected by federal confidentiality rules. If I have questions about disclosure of my health information, Ican contact the authorized individual or organization making disclosure.

****I have read the above foregoing authorization for Release of Information and do hereby acknowledge that I am familiar with and fully understand the terms and conditions of this authorization.

___________________________Signature of Patient/ Parent/ Guardian or Authorized Representative Date

___________________________Printed Name of Authorized Representative Relationship/ Capacity to Patient

PATIENT FINANCIAL RESPONSIBILITY FORM

Thank you for choosing D'Vida Injury Clinic & Wellness Center as your healthcare provider. We are honored by your choice and are committed to providing you with the highest quality healthcare. We ask that you read and sign this

form to acknowledge your understanding of our patient financial policies.

Patient Financial Responsibilities

• The patient (or patient’s guardian,) is ultimately responsible for the payment of his/her treatment and care.• We are pleased to assist you by billing for our contracted insurers however, the patient is required to provide us with the most correct andupdated information about their insurance and the patient will be responsible for any charges incurred if the information provided is notcorrect or updated.• Patients are responsible for the payment of co-pays, co-insurance, deductibles and all other procedures ortreatments not covered by their insurance plan. Payment is due at the time of service and for yourconvenience we accept cash, check, and most major credit cards at our office.Patients may incur, and are responsible for the payment of additional charges. These charges may include (but are not limited to):

• Charge of $25 for returned checks• There also may be fees applicable for medical record copies in the amount of $0.25 per page copied or $5.00 for every 100 pages on a

CD.• Charge of $35 for missed appointments without 24-hours advance notice. If you cancel your appointment without providing a 24-

hour advance notice, or no-show for an appointment or a last minute reschedule, there will be a $35.00 charge collected at your next appointment. Should the appointment reminder system fail or neglect to call you, the responsibility to know when your appointment is scheduled belongs to the patient and will not negate the $35.00 charge for missing an appointment.

By my signature below, I acknowledge and understand that it is ultimately my responsibility and obligation to be aware of my insurance’s requirements, coverages, deductibles and payments. Co-pays, Coinsurance,Time of Service Discount:I understand that I am responsible to pay in full prior to leaving. If I ask to be billed, I understand the that The Time of Service Discount will not apply & I will be charged the full Oregon Fee Schedule..

I acknowledge that I assume full financial responsibility for services rendered to me, if my insurance carrier denies or does not cover my claim for these services. I understand the terms of this form and accept financial responsibility with or without the use of insurance coverage.

Patient Authorization

• By my signature below, I hereby authorize D'Vida Injury Clinic & Wellness Center and the physicians, staff & any 3rd partybilling department to release medical and other information acquired in the course of my examination and/or treatment to thenecessary insurance companies, third-party payers, and/or other physicians or healthcare entities required to participate in mycare. I hereby authorize assignment of financial benefits directly to D'Vida Injury Clinic & Wellness Center and any associatedhealthcare entities for services rendered as allowable under standard third-party contracts. I understand that I am financiallyresponsible for charges not covered by this assignment. I understand thataccount balances not paid by my insurance company within 90 days are the patient’s/my responsibility. I authorize D'Vida Injury Clinic &Wellness Center personnel to communicate by mail, answering machine message, voice mail, and/or email according to the information Ihave provided in my patient registrationinformation.

I have read, understand, and agree to the provisions of this Patient Financial Responsibility Form:

_____________________________________________________________________________________________ Signature of Patient or Legal Guardian Date

Waiver of Authorization: I do not wish to have information released and prefer to pay at the time of service and/or to be fully responsible for payment of charges and /or to submit claims to insurance at my discretion.

_____________________________________________________________________________________________ Date Signature of Patient or Legal Guardian

3835 SW 185th Avenue Ste 400 Beaverton, OR 97078 T:503-626-2166 F: 503-641-6665