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New Patient Form

Complete The Following Form
Name
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How did you hear about us?

Primary (First) Complaint & Location

Please describe your symptoms

What makes it worse?

What makes it better?

Lifestyle

Review of Systems

Indicate which of the below you have experienced in the last 1-2 months 1=Never; 2=Rarely; 3=Occasionally; 4=Frequently; 5=Constantly

Eyes/Ears/Nose/Throat/Respiratory

Muscular/Skeletal

Neurological

General

Past Health History

Neurological Health History

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Musculoskeletal History

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Childhood Illness

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Adult Illnesses

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Past Surgeries

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Family Medical History

Father

Mother

Siblings

Spouse

Children

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation:

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AUTHORIZATION TO RELEASE MEDICAL RECORDS

to receive any of the information below in regards to my patient file at Prince Health and Wellness.
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FINANCIAL POLICY

1. Ultimately, the patient is responsible for all services rendered, including those not reimbursed by third party payers.

2. All payments are expected at the time of service, or at the beginning of treatment plan. Payment plans are available through the written authorization of Prince Health & Wellness.

3. All pricing set forth by Prince Health & Wellness LLC is subject to change at any time with notice. All Wellness Plans are subject to cancellation & re-activation fees.

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CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic manipulation, functional medicine, DNA testing, manual therapy techniques, and other chiropractic procedures, including various modes of physical therapeutic modalities and procedures and diagnostic X-rays, where warranted, on me (or on the patient named below, for whom I am legally responsible) by Dr. Ashley Prince, DC.

I have had an opportunity to discuss with Dr. Ashley Prince, DC the nature and purpose of chiropractic adjustments and other procedures. I understand that results are not guaranteed.

I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment and diagnostic services including but not limited to:

Manipulation: increased pain or discomfort, fractures, disc injuries, strokes, dislocations and sprains. Therapeutic Modalities and procedures: Additional pain and discomfort. Endurance exercise may cause increased risk of acute Myocardial Infarction (heart attack) in patients with known or possible cardiac conditions.

Radiographs: Ionizing radiation can be harmful to a fetus for those who are pregnant or might be pregnant.

I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely upon the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known to him or her, is in my best interest. Dr. Ashley Prince DC has additionally explained the risks associated with my refusal of treatment.

I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. 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.

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OFFICE POLICY

We believe that a clear definition of our office policies will allow you, the patient, and us, the doctor, to concentrate on the big issue - regaining and maintaining your health.

APPOINTMENT POLICY

Multiple appointments will be scheduled, for your convenience, to minimize waiting and to facilitate incorporating these appointments into your daily routine.

Regardless of how many appointments are scheduled for you each week, please note that it is the frequency of visits that counts, and not the days.

Therefore, if you are unable to keep an appointment for any reason, we require that you call immediately to reschedule your visit. It is your obligation to make up a missed appointment within 7 days of any cancellation.

The office reserves the right to charge for those appointments canceled without six hours notice. The cancellation fee is $25.

When entering the office on any given visit, please go directly to the front desk and "sign-in." We attempt to honor all appointments at the scheduled time. If you are late, you may have to wait for the next available appointment. If you have any questions regarding our office policy or your appointments, please do not hesitate to ask.

NOTICE OF PRIVACY PRACTICE

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

This notice takes effect on the date received and remains in effect until we replace it.

1. OUR PLEDGE REGARDING MEDICAL INFORMATION

This Notice explains how our office may collect, use and disclose your protected health information. It also explains your rights regarding your protected health information and the steps we take to keep your protected health information secure. "Protected health information" is information about you, including demographic information, that can reasonably be used to identify you and that relates to your past, present or future physical or mental health condition, the provision of care to you or the payment for that care.

Our office is required to provide you with this Notice by state and federal law. Some of the uses and disclosures described in this Notice may be limited in certain cases by applicable state laws that are more stringent than the federal standards. Our office is legally required to maintain the privacy of protected health information and to follow the privacy practices that are described in this Notice. However, we reserve the right to change the terms of this Notice and our privacy policies at any time. Any changes will apply to all the protected health information that we maintain, including any information we have created or received prior to issuing any new Notice. When we make an important change to our privacy policies, we will promptly change this Notice and post a new Notice in the office. You may also obtain any new Notice by asking for one at any time. This Notice goes into effect April 14, 2003.

2. USE AND DISCLOSURE OF YOUR MEDICAL INFORMATION Our office uses and discloses your protected health information for different reasons. We may collect and disclose protected health information from you and your other healthcare providers for the purposes of coordinating treatment, payment, or operating your health care plan. Any uses or disclosures other than those described herein will be made only with your prior written authorization, unless otherwise permitted or required by law. In the event, you authorize us to use or disclose your protected health information in ways other than those described above, you have the right to revoke that authorization at any time by delivering a written revocation statement, except to the extent that we have already disclosed the information or are allowed by law to use the information to contest a claim or coverage.

FOR TREATMENT: We may use and disclose your protected health information to assist in your diagnosis and treatment. For example, we may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.

FOR PAYMENT: We may use and disclose your protected health information in order to bill and collect payment for the treatment and services provided to you. For example, we may provide your protected health information to our billing department and your health plan to get reimbursed for health care services. We may also provide your protected health information to our business associates, such as billing companies, claims processing companies, and others that participate in claims payment process.

FOR HEALTH CARE OPTIONS: We may use and disclose your protected health information for activities necessary to operate your health care plan including quality management, utilization review, anti-fraud and claims payment, provider credentialing activities, underwriting, or determining premiums. We may also collect and disclose your protected health information as required by industry or government regulators such as the state licensing boards and insurance regulatory agencies. Our office may not use or disclose any more of your protected health information than is necessary to accomplish the purpose of the use or disclosure, except for treatment purposes.

ADDITIONAL USES AND DISCLOSURES: As required, we may also disclose protected health information to the sponsor of your health plan (usually your employer). Our office must disclose protected health information about you when required by law. Examples of such disclosures include the following:

Avoid Threat to Health or Safety: We may disclose protected health information to law enforcement personnel or persons able to prevent or lessen a serious threat to the health or safety of a person or the public.

Coroners, Funeral Directors, Organ Donation: We may disclose protected health information to coroners, medical examiners, and funeral directors as is necessary for such persons to carry out their duties. Additionally, we may disclose protected health information relating to organ, eye, or tissue donations and transplants.

Health Oversight Activities: We may disclose protected health information to assist the government agencies for activities allowed or required by law such as when it conducts an investigation or inspection of a health care organization.

Health-Related Benefits or Services: We may disclose protected health information to provide appointment reminders or give you information about treatment alternatives, or other health care services or benefits that may be of interest to you.

Law Enforcement, Judicial and Administrative Proceedings: We may disclose protected health information when ordered to do so in a judicial or administrative hearing. We may disclose protected health information in response to a subpoena, discovery request or other lawful process. Finally, we may disclose protected health information in response to a warrant, to identify or locate a suspect, or to provide information about the victim of a crime.

National Security and Intelligence: We may disclose protected health information as required by military officials for national security and military intelligence purposes.

Public Health Activities: We may disclose protected health information to public health agencies for reasons such as preventing or controlling disease, injury or disability.

Research: In certain circumstances, we may disclose protected health information in order to conduct medical research. Such circumstances include taking steps to protect your privacy.

Victims of Abuse, Neglect or Domestic Violence: We may disclose protected health information to government agencies and law enforcement personnel about victims of abuse, neglect, or domestic violence.

Workers' Compensation: We may provide protected health information in order to comply with workers' compensation laws.

3. YOUR INDIVIDUAL RIGHTS

Right to Request Restrictions on Uses and Disclosures of Protected Health Information: You have the right to request restrictions on the use and disclosure of your protected health information. To request a restriction please speak to our privacy officer. Please note that while you may request a restriction, we have a right to refuse that request. If we accept your request, we will put the limits in writing and abide by them except in emergency situations. You may not limit the uses and disclosures that we are legally required to make.

Right to Receive Confidential Communications: You have the right to receive confidential communications, including the right to direct where communications containing protected health information are sent. For example, you may request that information be sent to your work address rather than your home address or via alternative means such as email rather than regular mail. To verify or modify where or how you would like such communications sent, contact our privacy officer. We will accommodate all reasonable requests. Unless requested otherwise, we will direct mailings and telephone messages containing protected health information to the address and telephone number we have on record for the subscriber of the health plan.

Right to Inspect and Copy Protected Health Information: In most cases, you have the right to see and get copies of your protected health information that we maintain. If you want to see or get copies of your protected health information you must submit your request in writing to our privacy officer. If we do not have your protected health information but know who does, we will tell you where you can get it. We will respond to you within 30 days after receiving your written request. In certain situations, we may deny your request. If we do deny your request, we will tell you, in writing, the reasons for the denial and explain your right to have the denial reviewed. If you request copies of your protected health information, we will charge you a reasonable copying fee for each page and mailing costs but will inform you of that fee in advance. Instead of providing the protected health information you requested, we may provide you with a summary or explanation of the protected health information as long as you agree to the summary and any applicable charges in advance.

Right to Amend Protected Health Information: If you believe that there is a mistake in your protected health information or that a piece of important information is missing, you have the right to request that we correct the existing information or add the missing information. You must provide the request and your reasons for the request in writing to our privacy officer. We will respond within 60 days of receiving your request. We may deny your request in writing if the protected health information is (1) correct and complete, (2) not created by us, (3) not allowed to be disclosed or (4) not part of our records. Our written denial will state the reason for the denial and explain your right to file a written statement of disagreement with the denial. If you do not file a rebuttal, you have the right to request that copies of your initial request and our denial be attached to all future disclosures of your protected health information. If we approve your request, we will make the change to your protected health information, inform you when the change is completed, and inform others that need to know about the change to your protected health information,

Right to Receive an Accounting of Disclosures of Protected Health Information: You have a right to receive an accounting of any disclosures of your protected health information that were made for purposes other than coordinating treatment, payment or other health care services plan operations. The accounting will not include uses or disclosures made for treatment, payment, or health care operations, disclosures made directly to you or your family, or disclosures that you have already authorized. Additionally, the accounting will not include uses and disclosures made for national security purposes, or to corrections or law enforcement that has lawful custody over you. We will respond within 60 days of receiving your written request. The accounting will include the date of the disclosure, to whom protected health information was disclosed (including their address, if known), a brief description of the information disclosed, and a brief statement of the purpose for the disclosure. We will provide the first accounting you request within a 12-month period at no charge. For additional accountings within the same time period, we may charge you a fee for each additional request but will inform you of that fee in advance. To request an accounting of any such disclosures, submit your request in writing to our privacy officer stating the time period for which you want the accounting. This time period may not be longer than six years and may not include dates before April 14, 2003.

Right to Get a Paper Copy of this Notice: You have the right to get a paper copy of this Notice at any time even if you previously agreed to receive an electronic copy.

4. QUESTIONS & COMPLAINTS

Right to File a Complaint: If you believe that your protected health information has been improperly used or disclosed, or that your privacy rights have been violated you may file a privacy complaint with us. To file such a complaint, you should contact our privacy officer. You also have the right to file a complaint with the Secretary of the U.S. Department of Health and Human Services (DHHS). We will take no retaliatory action against you if you file a complaint with us or the DHHS.

VOLUNTARILY ELECTION TO NOT HAVE DIAGNOSTIC X-RAYS AND LIABILITY WAIVER

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In the course of a new patient consultation/examination performed by Dr. Ashley Prince, I was informed of the need for the diagnostic x-rays prior to an adjustment. Instead of waiting to take x-rays, I want to be adjusted today. And I have voluntarily elected not to have this diagnostic procedure performed. This is being done against the recommendations of the above named attending DC. I do not hold Dr. Ashley Prince, DC liable for any failure o diagnose or any misdiagnoses due to the lack of the recommended x-rays.

I assume full responsibility for any conditions relating to my health that may have been diagnosed had the recommended x-rays been taken.
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Disclaimer: The information provided on this website, by Prince Health & Wellness, is for general use only. Any statement or recommendation on this website does not take the place of medical advice nor is meant to replace the guidance of your licensed healthcare practitioner. These statements have not been evaluated by the food and drug administration. Prince health & wellness information is not and products are not intended to diagnose, cure, treat, or prevent any disease or provide medical advice. decisions to use supplements to support your specific needs should be considered in partnership with your licensed healthcare practitioner.
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