Thank you for choosing our team. How did you find out about us?

Were you referred by a patient who has seen us? Who?

Last Name: First Name:

Phone #: (H) Address: (W) (C) Cellular provider:

E-mail: Phone Text E-mail None

Would you like digital receipts? Would you like to receive newsletters & updates via e-mail?

Birthday: Marital Status: # of children:

Occupation: Emergency Contact: AHC #: Phone #:

Do you have extended health benefits? We offer direct billing for the following companies*:

Would you like to use direct billing?

If 'Yes' please provide the following information: Benefits ProviderYou are encouraged to bring your insurance Plan Member Namecard with you to ensure we have the correct ID #information. Group/Policy/Contract #

* Please note:a) Desjardins only allows for the plan member to receive reimbursement, therefore all fees incurred are still the patient's responsibility.

b) Manulife members must first authorize electronic statements through the plan member site in order to be eligible for these services.

c) In addition we are permitted to offer these services to RCMP, Canadian Forces & Veteran's Affairs. If unsure of your benefit

eligibility, it is advised that you speak with your benefits provider or our front desk staff for assistance; pre-authorization requirments

may apply.

If you are here for a claim, please specify what type: MVA WCB

Reason for appointment:How long have you had symptoms?How frequent are your symptoms?Have you experienced similar symptoms in the past?

Is this condition related to: Auto Date of accident/injury:Work

Please list any other healthcare professionals you are seeing for this condition:

Fx: (403) 277-2447

CHIROPRACTIC

www.chiro-doctor.comPh: (403) 277-9339 2713 Centre St NWCalgary, AB T2E 2V5

HealthC E N T R E

PATIENT INFORMATION

HEALTH CLAIM INFORMATION

TODAY'S VISIT

M F

Y N

Y

Y

N

N

S M D W CL

(for text reminders)

(mm/dd/yyyy)

Y N

Reminder Pref.:

Y N

Postal Code:

If anything in this section doesn't apply to you, please put N/A in the space provided.

Have you had previous chiropractic care? Doctor's name:Have you had X-Rays, MRI or other tests for this condition? When? Where?Please list any surgeries and their dates:

Please list any major injuries or illnesses and their dates:

Please list ALL medications you are taking (Prescription & Non-prescription):

These conditions are extremely important to your chiropractic care. Please be thorough. Mark whether you've experienced these conditions in the past and/or are presently.

Past Present Past Present Past Present

FaintingLow blood pressure High blood pressure Smoker

Diabetes For how long?

Whiplash injury Hardening of arteries Visual disturbances

Tuberculosis Speech problems Hearing disturbances

Cancer Difficulty swallowing Heart or blood disease If yes, where? Dizziness

Loss of consciousness Stroke Sudden collapse without

Has a relative had a stroke? loss of consciousness Who? Numbness or weakness in the face, fingers, hands, arms,

Bone spurs in neck legs, or other extremities or cervical sprain

Indicate the location(s) where you have pain.

On a scale of 1 to 10, (1 being no pain), how severe is your pain?

Fx: (403) 277-2447

YOUR HEALTH HISTORY

2713 Centre St NW

CHIROPRACTIC

HealthC E N T R E

Ph: (403) 277-9339Calgary, AB T2E 2V5

YY

NN

www.chiro-doctor.com

Please mark whether you have experienced these symptoms in the past and/or are presently: Past Present Past Present Past Present

Fever Chronic cough Frequent urination

Sweats Spitting up phlegm Painful urination

Sleep disturbance Spitting up blood Blood in urine

Fatigue Chest pain Pus in urine

Nervousness Wheezing Kidney infection/Kidney stones

Weight change Difficulty breathing Prostate trouble

Allergies Asthma Uncontrollable urine flow

Past Present Past Present Past Present Poor appetite Rapid heart rate Convulsions

Difficult digestion Slow heart rate Headache

Heartburn Pain over heart Neuralgia (nerve pain)

Nausea Swollen ankles Poor coordination

Vomiting Poor circulation Weakness

Constipation Palpitations

Diarrhea Varicose veins

Blood in stool Cold hands or feet

Gallbladder/jaundice Past Present

Colitis Hot flashes

Past Present Past Present Irregular cycle

Eye pain Neck pain Cramps or back pain

Double vision Low back pain Vaginal discharge

Ringing in ears Arm pain Nipple discharge

Deafness Shoulder pain Lumps in breast

Nosebleeds Leg pain Painful menstruation

Trouble swallowing Knee pain Birth control

Hoarseness Foot pain Type?

Sinus infection Pain between shoulders Complications with

Nasal drainage Fractures pregnancy

Enlarged glands Swollen joints Pregnant

Spinal curvature Weeks?

Arthritis Menopausal symptoms

Fx: (403) 277-2447

CHIROPRACTIC

HealthC E N T R E

Ph: (403) 277-9339 www.chiro-doctor.com 2713 Centre St NWCalgary, AB T2E 2V5

GEN

ERA

LSY

MPT

OM

S

RES

PIR

AT

OR

Y

GEN

ITO

UR

INA

RY

GA

STR

OIN

TES

TIN

AL

CA

RD

IOV

ASC

ULA

R

NEU

RO

LOG

ICA

L

EEN

T

MU

SCLE

& J

OIN

T

*WO

MEN

ON

LY*

Canadian Chiropractic Protective Association Informed Consent to Chiropractic Treatment, Form L

There are risks and possible risks associated with manual therapy techniques used by doctors of chiropractic. In particular you should note:

a) While rare, some patients may experience short term aggravation of symptoms or muscle and ligament strains or sprains as a result of manual therapy techniques. Although uncommon, rib fractures have also been known to occur following certain manual therapy procedures.

b) There are reported cases of stroke associated with visits to medical doctors and chiropractors. Research and scientific evidence does not establish a cause and effect relationship between chiropractic treatment and the occurrence of stroke. Recent studies suggest that patients may be consulting medical and chiropractors when they are in the early stages of a stroke. In essence, there is a stroke already in progress. However, you are being informed of this reported association because a stroke may cause serious neurological impairment or even death. The possibility of such injuries occuring in association with upper cervical adjustment is extremely remote.

c) There are rare reported cases of disc injuries identified following cervical and lumbar spinal adjustment, although no scientific evidence has demonstrated such injuries are caused, or may be caused, by spinal adjustments or other chiropractic treatment.

d) there are infrequent reported cases of burns or skin irritation in association with the use of some types of electrical therapy offered by some doctors of chiropractic.

I acknowledge I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, (including spinal adjustment), the treatment options and recommendations for my condition, and the contents of this consent.

I consent to the chiropractic treatment recommended to me by my chiropractor including any recommended spinal adjustments.

I intend this consent to apply to all my present and future chiropractic care.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original.

Patient/Legal guardian signature Witness signature

Printed name Witness name

Date

Fx: (403) 277-2447Ph: (403) 277-9339 www.chiro-doctor.com 2713 Centre St NW

Calgary, AB T2E 2V5

CHIROPRACTIC

HealthC E N T R E

All fees incurred for treatment are payable upon services rendered. Fee schedule is as follows:

Cancellation PoliciesWe appreciate your decision in making us your choice in chiropractic, please respect the

needs of our other patients and make any appointment cancellations in a timely manner. We require at least 24 hours notice for any appointment changes or cancellations. Any late cancellations or no shows will be billed for the full price of their office visit. Please note that missed or cancelled appointments will be your responsibility as they are not eligible for reimbursement through any health benefits provider. If care is suspended or terminated, any and all oustanding charges for professional services rendered to or for you will be immediately due and payable to the clinic.

Privacy PoliciesWe maintain a very high standard for the protection of the confidentiality and integrity of

individual personal health information. If any identifying health information is to be disclosed to another party or we require information to be released to us for the purposes of providing ongoing care; express written consent will be obtained. If you have any questions regarding your privacy concerns, feel free to direct any inquiries to the front desk.

I have read an understand the above policies and procedures that are in place and agree to the terms that are defined.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original.

Patient/(Legal guardian) signature: Printed name

Date

Fx: (403) 277-2447

Initial VisitAdult

Senior (65 & over)Student (13-17)

Child (12 & under)

Ph: (403) 277-9339 www.chiro-doctor.com 2713 Centre St NWCalgary, AB T2E 2V5

CHIROPRACTIC

HealthC E N T R E

Subsequent Visits$55$44$44$35

$109$89$89$74

Electronic Transmission Authorization and Consent

Patient Name:

Benefits Provider:Plan Member Name:

ID #: Group/Policy/Contract #:

Service Provider: Chiropractic Health Centre

Consent for Collection and Disclosure of Personal InformationPersonal information that we collect in regards to extended health care is disclosed solely for the

purposes of determining eligibility and administering the benefits plan, this includes the investigation of fraud and/or plan abuse.

Authorization for the Release of InformationI confirm that I, if not the plan member, am authorized by the individual to release any information

regarding them for the aforementioned purposes.I permit Chiropractic Health Centre to collect, use, and disclose the necessary information needed in

the processing of my extended health care claims.In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims

submitted I acknowledge and agree that my benefits provider and Chiropractic Health Centre may use and disclose any relevant personal information to each other for the purpose of investigation and prevention of fraud and/or plan abuse.

Assignment of BenefitsI agree to assign any benefits that are paid for my eligible claims to Chiropractic Health Centre and

authorize my benefits provider to issue payment directly to them. In the event any submitted claim(s) are declined or only partially covered, I understand that I will remain responsible for the cost of the services rendered. If any outstanding balances occur from this and legal action becomes necessary to collect on this amount, I understand that I will be responsible for all attorney and legal fees incurred.

I understand the above terms and agree that this authorization is to apply to all eligible claim(s) submitted electronically by Chiropractic Health Centre, and that I may revoke authorization at any time by providing written notice.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

Patient/legal guardian signature Printed name

Date

Fx: (403) 277-24472713 Centre St NW

Calgary, AB T2E 2V5

CHIROPRACTIC

HealthC E N T R E

Ph: (403) 277-9339 www.chiro-doctor.com

PRINT

Last Name: First Name: Address 1: Address 2: Email: Birthday: of children: Occupation: Reason for appointment: How long have you had symptoms: How frequent are your symptoms: Please list any surgeries and their dates: Please list any major injuries or illnesses and their dates: Gender: Female: Gender: Male: Contact: Phone: Contact: E-mail: Contact: None: Contact: Text: Digital Receipts: No: Digital Receipts: Yes: Updates: No: Updates: Yes: Marital Status: Married: Marital Status: Divorced: Marital Status: Widowed: Marital Status: Common Law: Marital Status: Single: Health Benefits: No: Health Benefits: Yes: Direct Bill: No: Direct Bill: Yes: Similar Symptoms: No: Similar Symptoms: Yes: Condition: Work: Condition: Auto: Previous Care: No: Previous Care: Yes: Imaging: Yes: Imaging: No: Cellular Provider: BellDirect Billing Companies: Johnson IncPresent: Low Blood Pressure: Past: Low Blood Pressure: Present: High Blood Pressure: Past: High Blood Pressure: Claim: Car Accident: Claim: Worker's Comp: Past: Diabetes: Present: Diabetes: Past: Tuberculosis: Present: Tuberculosis: Past: Cancer: Present: Cancer: Past: Stroke: Present: Stroke: Past: Bone Spurs: Present: Bone Spurs: Past: Fainting: Present: Fainting: Past: Smoker: Present: Smoker: Past: Speech Problems: Present: Speech Problems: Past: Difficulty Swallowing: Present: Difficulty Swallowing: Past: Dizziness: Present: Dizziness: Past: Sudden Collapse: Present: Sudden Collapse: Past: Numbness: Present: Numbness: Past: Whiplash: Present: Hardening of Arteries: Past: Hardening of Arteries: Present: Whiplash: Past: Visual Disturbances: Present: Hearing Disturbances: Past: Hearing Disturbances: Present: Visual Disturbances: Past: Heart/Blood Disease: Present: Heart/Blood Disease: Past: Loss of Consciousness: Who? What? Where? How?: First & Last Name: Home Phone: Work Phone: Cell Phone: Alberta Health Care #: Emergency Contact Phone #: Emergency Contact Name: ID: Usually 9-11 Digits: Group: Usually 2-6 Digits: (mm/dd/yyyy): List of practitioners you are seeing: Doctor's name: Month/Year: Country/Province/City: Please list any surgeries and their dates 2: List of practitioners you are seeing 2: Please list any major injuries or illnesses and their dates 2: List all medications you take: List all medications you take 2: Part of Body: Relation to You: Months/Years: 1-10: Present: Loss of Consciousness: Left Jaw 1: Left Elbow 1: Abdomen 1: Left Hip 1: Left Ribs 1: Right Hip 1: Left Shin 1: Left Foot 1: Head 1: Right Neck 2: Left Neck 1: Left Neck 2: Left Shoulder 1: Right Shoulder 2: Upper Chest 1: Upper Back 1: Left Shoulder 2: Right Shoulder Blade 1: Right Upper Arm 1: Left Upper Arm 1: Left Upper Arm 2: Left Shoulder Blade 1: Right Back 1: Right Lower Back 1: Left Lower Back 1: Right Elbow 1: Left Elbow 2: Right Lower Arm 1: Left Lower Arm 1: Left Lower Arm 2: Right Wrist 1: Left Wrist 1: Left Wrist 2: Right Hand 1: Left Hand 1: Left Hand 2: Left Back 1: Left Hip 2: Right Thigh 1: Left Thigh 1: Left Thigh 2: Left Knee 1: Left Knee 2: Right Knee 1: Right Shin 1: Left Calf 1: Left Ankle 1: Left Ankle 2: Right Ankle 1: Right Foot 1: Left Foot 2: Head 3: Head 2: Right Jaw 1: Right Neck 1: Right Shoulder 1: Right Upper Arm 2: Right Elbow 2: Right Lower Arm 2: Right Wrist 2: Right Hand 2: Right Hip 2: Right Ribs 1: Right Thigh 2: Right Knee 2: Right Calf 1: Right Ankle 2: Right Foot 2: Head 4: Head 5: Right Jaw 2: Left Jaw 2: Right Neck 3: Left Neck 3: Right Shoulder 3: Left Shoulder 3: Right Upper Arm 3: Left Upper Arm 3: Right Elbow 3: Left Elbow 3: Right Lower Arm 3: Left Lower Arm 3: Right Wrist 3: Left Wrist 3: Right Hand 3: Left Hand 3: Right Side 1: Left Side 1: Right Ribs 2: Left Ribs 2: Right Thigh 3: Left Thigh 3: Right Knee 3: Left Knee 3: Right Calf 2: Left Calf 2: Right Ankle 3: Left Ankle 3: Right Foot 3: Left Foot 3: Head 6: Head 7: Past: Fever: Past: Sweats: Past: Sleep disturbance: Past: Fatigue: Past: Nervousness: Past: Weight Change: Past: Allergies: Present: Fever: Present: Sweats: Present: Sleep disturbance: Present: Fatigue: Present: Nervousness: Present: Weight Change: Present: Allergies: Present: Frequent urination: Present: Painful urination: Present: Blood in urine: Present: Pus in urine: Present: Kidney infection/kidney stones: Present: Prostate trouble: Past: Chronic cough: Past: Spitting up phlegm: Past: Spitting up blood: Past: Chest pain: Past: Wheezing: Past: Difficulty breathing: Past: Asthma: Present: Chronic cough: Present: Spitting up phlegm: Present: Spitting up blood: Present: Chest pain: Present: Wheezing: Present: Difficulty breathing: Present: Asthma: Present: Uncontrollable urine flow: Present: Eye pain: Past: Frequent urination: Past: Painful urination: Past: Blood in urine: Past: Pus in urine: Past: Kidney infection/kidney stones: Past: Prostate trouble: Past: Uncontrollable urine flow: Past: Poor appetite: Past: Difficult digestion: Past: Heartburn: Past: Nausea: Past: Vomiting: Past: Constipation: Past: Diarrhea: Past: Blood in stool: Past: Gallbladder/jaundice: Past: Colitis: Present: Poor appetite: Present: Difficult digestion: Present: Heartburn: Present: Nausea: Present: Vomiting: Present: Constipation: Present: Diarrhea: Present: Blood in stool: Present: Gallbladder/jaudice: Present: Colitis: Present: Rapid heart rate: Present: Slow heart rate: Present: Pain over heart: Present: Swollen ankles: Present: Poor circulation: Present: Palpitations: Present: Varicose veins: Present: Cold hands or feet: Past: Rapid heart rate: Past: Slow heart rate: Past: Pain over heart: Past: Swollen ankles: Past: Poor circulation: Past: Palpitations: Past: Varicose veins: Past: Cold hands or feet: Past: Convulsions: Past: Headache: Past: Neuralgia: Past: Poor coordination: Past: Weakness: Present: Convulsions: Present: Headache: Present: Neuralgia: Present: Poor coordination: Present: Weakness: Past: Eye pain: Past: Double vision: Past: Ringing in ears: Past: Deafness: Past: Nosebleeds: Past: Trouble swallowing: Past: Hoarseness: Past: Sinus infection: Past: Nasal drainage: Past: Enlarged glands: Present: Double vision: Present: Ringing in ears: Present: Deafness: Present: Nosebleeds: Present: Trouble swallowing: Present: Hoarseness: Present: Sinus infection: Present: Nasal drainage: Present: Enlarged glands: Past: Neck pain: Past: Low back pain: Past: Arm pain: Past: Shoulder pain: Past: Leg pain: Past: Knee pain: Past: Foot pain: Past: Pain between shoulders: Past: Fractures: Past: Swollen joints: Past: Spinal curvature: Present: Neck pain: Present: Low back pain: Present: Arm pain: Present: Shoulder pain: Present: Leg pain: Present: Knee pain: Present: Foot pain: Present: Pain between shoulders: Present: Fractures: Present: Swollen joints: Present: Spinal curvature: Present: Arthritis: Past: Arthritis: Present: Hot flashes: Present: Irregular cycle: Present: Cramps/back pain: Present: Vaginal discharge: Present: Nipple discharge: Present: Lumps in breast: Present: Painful menstruation: Present: Birth control: Present: Complications with pregnancy: Present: Pregnant: Present: Menopausal symptoms: Past: Hot flashes: Past: Irregular cycle: Past: Cramps/back pain: Past: Vaginal discharge: Past: Nipple discharge: Past: Lumps in breast: Past: Painful menstruation: Past: Birth control: Past: Complications with pregnancy: Past: Menopausal symptoms: Printed name: Witness name: Today's Date: Patient Name: Insurance Company:

Plan Member Name:

ID #: Group/Policy/Contract #: Patient Name 2: Today's Date 2: Patient Name 1: Today's Date 1: PRINT: