Dr. Jerrid Goebel Licensed Acupuncturist 824 1st Street
Dr. Stuart Johnson Sturgis, South Dakota, 57785
Dr. Al Gunderson Telephone (605) 347-4003
Todays date: ______________
Date of Birth_______________ age____
Gender:M / F
Marital Status: M / S / D / W
Spouse’s or Parent’s Name___________________________
Preferred Language__________________ White Asian Hispanic
Race: American Indian or Alaska Native Black or African American
Hawaiian/Other Pacific Island
Home Phone ____________ Work ______________ Cell_____________ Email __________________Referred By: Yellow Pages____ Doctor_ _____ ___ Other_ _____ ___
Newspaper____ Friend_ _____ ___ Radio____ Family_ _____ ___
Insured Name(if not patient)______________
(We will photocopy insurance card)
Insured date of birth_____________________
What is the main reason for visiting our office today? _________________________________________
How long have you had this condition? _____________________ Date of Incident ____/____/_____
Work Related? _____________ Auto Accident? ____________ Other Type of Accident? ____________
Have you had this or similar conditions in the past? __________________________________________
(If so, please explain)
Is this condition interfering with: Work ____ Sleep ____ Daily Routine ____ Other____________________
Other doctors or therapists who have treated THIS Condition: ___________________________________
Has this condition: Improved _____________ Unchanged _____________ Worsened _____________
Family Physician: Name__________________________ Date of Last Wellness Exam: ____/____/_____
Do you have a Pacemaker? YES NO Recent Surgeries/Dates: ______________________________
Current Height _____ Weight _____ lost or gained weight? __________ b/p(staff will check)
_____ / ____
Smoking status- Never ___ Former ____ Current some day ___ Current every day___
(we will make a copy if a list is available)
Check any of the boxes that apply to you, CURRENT or PAST.
Loss of Sensation
Difficulty with Speech
Loss of Memory
Any other comments? ______________________________________________________________
Mental Work Heavy
Light Hours per day __________
Physical Work Heavy
Light Hours per day __________
Light Hours per week ____ Type __________
Beer/ Week_____ Liquor/ Week _____ Wine/ Week_____
No. of Years_____
Cups/ Day _____
No. of Years _____
No./ Day _____
No. of Years _____
Place an X on the line where it applies:
How bad are the symptoms now?
How bad were the symptoms in the past?
ACKNOWLEDGEMENT OF NOTICE
You May Refuse to Sign This Acknowledgement*
I have been offered/ received a copy of this office’s Notice of Privacy Practices.___________________________________________ ______________________________________ ____________
Please Print Name Signature Date
We attempted to obtain written acknowledgement of our Notice Of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign
Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement
Other (Please Specify): ______________________________________________________________________
I, __________________________, herby acknowledge that my insurance plan my not pay for all charges
incurred in this office, such as exams, x-rays, heel lifts, or my Deductible. I acknowledge that I am
responsible for any charges refused or not covered by my insurance company. Further, I will pay for my
collections or legal charges incurred in the collection of these uncovered charges should I fail to pay them
during the agreed upon time. I hereby authorize the doctor to release all information necessary to secure the
payments of benefits. I authorize the use of my signature on all my insurance submissions whether manual or
__________________________________________ Date______________Signature of insured/ guardian
I request the payment of authorized Medicare benefits be made either to me or on my behalf to Sturgis
Chiropractic, P.C. for any services furnished to me by the physician. I authorize any holder of medical
information about me to be released to the Health Care Financing Administration and its agents any
information needed to determine these benefits or the benefits payable for related services. I understand my
signature requests that payments be made and authorizes release of medical information necessary to pay the
claim. If “other insurance” is indicated on item nine of the HCFA- 1500 form or elsewhere on other approved
forms or electronically submitted claims, my signature authorized release of the information to the insurer or
agency shown. In Medicare assigned cases, the physician or supplier agrees to accept the charge of
determination of the Medicare carrier as the full charge, and the PATIENT IS RESPONSIBLE FOR ANY NON-
COVERED CHARGES SUCH AS X-RAYS, EXAMS, COINSURANCE, AND/ OR DEDUCTIBLE. Coinsurance
and the deductible are based upon the charge determination of the Medicare carrier.
Please realize that your health insurance is your insurance, not ours. We will do everything possible to help you get reimbursed from your insurance carrier, but the ultimate obligation for payment rests with you, the patient, not with the insurance company. Co-pay is expected at the time of service. If your insurance deductible for the year has not been
met at the time of service, payment is expected in full on that day of service.
For office visits, treatment, x-rays, or supplies, please pay at the time of service. We gladly accept cash, check, MasterCard and Visa
If you are a cash patient, payment is expected at time of service. We gladly accept cash, check, MasterCard and Visa.
We will file directly with Medicare and/or your supplemental insurance for you, but you are responsible for the charges that Medicare or your supplement does not cover or pay. If your Medicare deductible for the year has not been met and your
supplement does not cover it, payment is expected in full on that day of service.
You must have a current Medicaid monthly eligibility card and bring it to each visit. Cost-Share portion is expected at
the time of service.
WORKMAN’S COMPENSATION / MVA
If you are here because of a work related injury / MVA, we must verify the coverage of your medical bills from your employer and / or your MVA carrier, we need exact information from you on the time, location and nature of your injury.
Please bring this information with you and notify the receptionist that you are covered under worker’s compensation or automobile insurance. If for some reason the worker’s compensation or MVA information is not verified, then you,
the patient, are responsible for the charges.
If the account must be turned over to collection, all costs and fees associated with such collections are the responsibility of the patient. Once accounts are turned over for collection, payments are due to collection agency.
Consent To Treat Patient Name:_________________________________
To the patient: Please read this entire document prior to signing it. It is important that you understand the information contained in this document. Please ask questions before you sign, if there is anything that is unclear.
I acknowledge by my signature below that my Doctor of Chiropractic has discussed the proposed treatment with me and any material risks and expected benefits of that treatment. I have been given the opportunity to ask questions and any questions I had have been answered to my satisfaction.
The nature of the chiropractic adjustment
The primary treatment used by a Doctor of Chiropractic is spinal manipulative therapy which will be used to treat you. Your chiropractor may use their hands or mechanical instrument(s) upon your body in such a way as to move your joints. That may cause an audible “pop” or “click”, much as you have experienced when you “crack” your knuckles. You may feel a sense of movement.
As a part of the analysis, examination, and treatment, I am aware and consent to the following procedures which may be used in my chiropractic care: Spinal Manipulative Therapy, Range of Motion Testing, Muscle Strength Testing,
ultrasound, radiographic studies, basic neurological testing, palpation, orthopedic testing, postural analysis, hot/cold therapy, electrical stimulation, vital signs.
The material risks inherent with chiropractic adjustments
As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation and therapy. These complications include but are not limited to: fractures, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations, and burns. Some patients will feel some stiffness and soreness following the first few days of treatment. We will make every reasonable effort during the examination to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.
The probability of those risks occurring
Fractures are rare occurrences and generally result from some underlying weakness of the bone which we check for during the taking of your history and during examination and X-ray.
The availability and nature of other treatment options
Other treatment options for your condition may include: Self-administered, over-the-counter analgesics and rest
Medical care and prescription drugs such as anti-inflammatory, muscle relaxants and pain killers Hospitalization
If you choose to use one of the above noted “other treatment” options, you should be aware that there are risks and benefits of each such option and you should discuss these with you primary care physician.
The risks and dangers to remaining untreated
Remaining untreated may allow the formation of adhesions and reduce mobility which may set up a pain reaction further reducing mobility. Over time this process may complicate treatment making it more difficult and less effective the longer it is postponed.
DO NOT SIGN UNTIL YOU HAVE READ AND UNDERSTAND THE ABOVE.
By signing below, I state that I have weighed the risks involved in undergoing treatment and have decided that it is in my best interest to undergo the recommended treatment. Having been informed of the risks, I hereby give my consent to that treatment.
________________________ __________________________ Patient’s Name (printed) Doctor’s Name (printed)