New Patients

Fill-out our New Patient Registration form first. Go ahead and do this now.

Confidential Patient Health Record  
       
How did you hear about us?

   
       
Personal Information
       
First Name: Middle Name:
Last Name: Sex:

Address: Apt#
State: Zip:
County: Country:
Home Phone: Cell Phone:
Status:

Birth Date:
Age: Social Security #:
Fax: Driver’s
License #:
State: Email Address:
Spouse’s Name: Spouse’s Date of Birth
Children (Names and Ages):    
Emergency Contact
    
       
Name: Phone Number:
Address: Relationship:

Current Health Condition
    
   
Unwanted Condition (Why you are here today?):
Use the letters BELOW to indicate the TYPE and LOCATION of your sensations right now.
Key: A=Ache B=Burning N = Numbness
P=Pins & Needles S=Stabbing		  
 
When did this Condition BEGIN?  
Has it ever occurred before?
Yes No
In this Condition:
Auto Related Job Related Home Injury Slip For Fall
Lifting Slept Wrong Unknown
Cause
Explain:    
Date of Accident:
Time of Accident:
Condition/Pain STARTED on what Date:
Have you seen other doctors for THIS CONDITION?
Yes No
If yes, Who? (Name)  
       
Injury (ies):
Mark or List All Injuries. Write the DATE of the Injury immediately afterward.
       
       
Social History:
Mark all that apply below.
     
Tobacco:
   
     
Smoke:
Chew:
Employment Information
   
Business Name:
Occupation/Job Title:
Business Address:
Name of Supervisor:
Business Phone:
Type of Work:
Workers Compensation Injury / Auto / Personal Injury:
     
Have you filed an injury report with your employer? Yes No
Date Time am/pm
Carrier: Policy #
Carriers Phone #: Adjuster:
Claim #:    

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understandthat the Chiropractic Clinic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that anyamount authorized to be paid directly to the Chiropractic Clinic will be credited to my account upon receipt. However, I clearly understand and agreethat all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care or treatment, any fees for professional services rendered me will be immediately due and payable.

I hereby authorize the Doctor to treat my condition as he or she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid the Doctor, for x-rays, is for examination only and the x-ray negative will remain the property of this 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.

Patient Print Name:
Patient’s Signature:
Date:
Consent to treat a Minor: Date:
Guardian or Spouse’s Signature of Authorizing Care: Date:
I acknowledge that I have received the Chiropractic Clinic’s Notice of Privacy Practices for protected health information.
Patient Print Name: Date:
Patient’s Signature: Date:

What to Expect From Your ProAdjuster™ Doctor of Chiropractic

First, Dr. Petrucci will talk with you to determine your medical history and the possible causes of your problem. The adjustment and treatment procedures then can be customized to fit each patient’s needs.

Each patient has different needs, and Dr. Petrucci will combine manual chiropractic adjustment with the advanced technology of the ProAdjuster™ to help you heal as quickly as possible.

The next step in evaluation and treatment is to utilize the ProAdjuster’s™ sophisticated computerized analysis to pinpoint the problem areas. The information is then charted graphically on a computer monitor, so your doctor can detect the problem areas on each and every visit.

By applying the ProAdjuster’s™ resonant force impulses precisely to the affected areas, you will receive gentle, effective treatment to that specific area, thereby reducing the subluxation. This will relieve the pressure on the nerve, allow the nerve to heal and restore the nerve’s ability to transmit signals to and from the brain more freely. Most importantly, it will help relieve the pain!

In addition, your doctor may again take the readings after the adjustment with the ProAdjuster™ to compare the results, then modify your treatment plan accordingly.