Patient Questionnaire Step 1 of 2 50% Patient InformationName First Last Date of BirthMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell PhoneHome PhoneEmergency Contact NamePhoneEmail Enter Email Confirm Email Patient ConditionMy primary health complain for which I am seeking laser treatment is:Laser therapy is a safe, non-invasive FDA cleared modality. The following questions are a tool to help your clinician determine if you are a candidate for laser therapy. If you answer ‘yes’ to any of these questions you will need to discuss details of your condition with your clinician. Do you have a pacemaker or any other implanted device(s)? Yes No Are you pregnant? Yes No Do you have cancer or have you had cancer in the past? Yes No Are you taking medication that may increase sensitivity to light? Yes No Have you had a steroid injection in the last 7 days? Yes No Terms of Acceptance & Informed ConsentInformed Consent: Laser therapy is a safe, non-invasive, FDA cleared modality for the treatment of pain, inflammation and the temporary increase of microcirculation. Increased microcirculation can provide relief for many acute and chronic conditions. Laser therapy utilizes visible and invisible laser radiation, therefore, appropriate eye protection is necessary and required at all times during treatment. Effects of treatment will continue for up to 18 hours. Individuals respond uniquely to treatment. You may see immediate results after the first treatment or depending on the severity of your condition you may require several treatments before you begin to feel results. The average patient’s condition requires 10-12 deep tissue laser treatments for the best outcome. Increased soreness may occur after your first laser session. This is a normal healing phenomenon. Mild bruising may occur from the soft tissue manual therapy element of your treatment program.The above is a true and honest representation of my condition. I understand the above, consent to treatment and understand there is no guarantee of success. I understand that failing to complete any part of my treatment program will reduce my chances of success. All of my questions regarding safety and the potential success of treatment have been answered to my full satisfaction. Acceptance of Terms of Acceptance/Informed Consent I have read and accept the above terms. I do not accept the above terms. Assignment, Release of Benefits and Guarantee of PaymentBy clicking the button below, I certify that to the best of my knowledge the information on this form is accurate, truthful and current. I certify that I, and/or my dependent(s) have insurance coverage with the aforementioned company(s) and assign directly to Laser Pain Relief Center a division of Laser Pain Relief Centers a division of Laser Relief Centers a division of Madeira Chiropractic Wellness Center, Inc. all insurance benefits, if any, otherwise payable to me for services rendered. I understand that 1) I am financially responsible for all charges whether or not paid by insurance and 2) I am financially responsible for any legal fees or other fees incurred by Laser Pain Relief Center a division of Laser Pain Relief Centers a division of Laser Relief Centers a division of Madeira Chiropractic Wellness Center, Inc. for collection efforts of delinquent balances on my and/or my dependent(s) account(s). I authorize the use of my signature on all insurance submissions. Laser Pain Relief Center a division of Laser Pain Relief Centers a division of Laser Relief Centers a division of Madeira Chiropractic Wellness Center, Inc. may use my healthcare information and may disclose such information to the above-named insurance company(s) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. The consent will end when my current treatment plan is completed or one year from the date below. I consent to treatment for myself and/or treatment of my minor dependent(s) and guarantee payment for all services rendered by Laser Pain Relief Center a division of Laser Pain Relief Centers a division of Laser Relief Centers a division of Madeira Chiropractic Wellness Center, Inc. whether insurance pays or not. Acceptance of Assignment, Release of Benefits and Guarantee of Payment I have read and accept the above terms. I do not accept the above terms. Notice of Privacy PracticesI acknowledge that I have had the opportunity to review Laser Pain Relief Center a division of Madeira Chiropractic Wellness Center, Inc.’s "Notice of Privacy Practices" on the practice’s website online. I understand I have a right to review Laser Pain Relief Center a division of Madeira Chiropractic Wellness Center, Inc.’s Office Privacy Policy prior to accepting this document. The Notice of Privacy Practices describes the types of uses and disclosures of protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Laser Pain Relief Center a division of Madeira Chiropractic Wellness Center, Inc. The Notice of Privacy Practices is also provided on request at the main administration desk of the practice. This Notice of Privacy Practices describes my rights and Laser Pain Relief Center a division of Madeira Chiropractic Wellness Center, Inc.’s duties with respect to my protected health information. Laser Pain Relief Center a division of Madeira Chiropractic Wellness Center, Inc. reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy to be sent in the mail, email or asking for one at the time of my next appointment. Acceptance of Notice of Privacy Practices I have read and accept the above terms. I do not accept the above terms. EmailThis field is for validation purposes and should be left unchanged.
