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New Patient Paperwork

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Personal Information
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Nature of Injury*
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Do you have health insurance?

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Ace Chiropractic Clinic requests 24 hours notice for any changes to an appointment including rescheduling, cancelling, "no show", or changes to therapies booked for the appointment time. This policy is in place to be courteous to other patients in need of treatment at the clinic. I understand that in the event of a violation of this policy Ace Chiropractic Clinic reserves the right to charge me their cancellation fee of $50. This fee is to be paid prior to receiving any additional treatment or services.

Please enter or fix values for the indicated fields.
Health History
Have you been treated for this same condition elsewhere?
Have you had X-Rays taken?
Have you been to a chiropractor before?
Broken bones?
Been hospitalized?
Been in an auto accident?
Had sprains/strains?
Been struck unconscious?
Had surgery?
Do you experience pain every day?
Do your symptoms interfere with daily life?
Does pain wake you up at night?
Are your symptoms worse during certain times of the day?
Do changes in weather affect your symptoms?
Do you wear orthotics?
Alcohol:
Tobacco:
Drugs
Exercise:
Sleep
Appetite:
Have you ever suffered from:
Please use the following letters to indicate type and location of the symptoms you currently are experiencing: A– Ache, B– Burning, N– Numbness, P– Pins & Needles, S– Stabbing, T– Tingling, O– Other (please specify)

AUTO ACCIDENT INFORMATION

Time Period
Were you the*
Please select at least one option
Is there Med Pay on this plan?
Did the police come to the accident site?
Was a police report filed?
Were there any witnesses?
Were you wearing a seatbelt?
Was this vehicle equipped with airbags?
If yes, did it/they inflate?
In relation to the base of your skull, where was the headrest?
What did your vehicle impact?
Did any part of your body strike anything in the vehicle?
Did the impact to your vehicle come from the
During impact, were you facing
Immediately at time of impact were you
Did the accident render you unconscious?
Have you gone to a hospital or seen any other doctor?

If yes...

When did you go?
How did you get there?
Did you see a:
Were any X-Rays taken?
Was any medication prescribed?
Have you been able to work since this injury?
Are your work activities restricted as a result of this injury?
Indicate the symptoms that are a result of this accident:*
Please select at least one option
Is your condition getting worse?

Indicate your degree of discomfort while performing the following activities:

Lying on Back
Lying on Side
Lying on Stomach
Sitting
Standing
Stretching
Walking
Running
Sports
Working
Lifting
Bending
Kneeling
Pulling
Reaching
Have you retained an attorney?*
Please select one option

Recovery

Please indicate your daily job duties and any activities which you are occasionally asked to perform
Prior to the injury were you capable of working on an equal basis with others your age?
While in recovery, is there any light duty work you could request?

Activities of Daily Living

Please check each of the activities which you have difficulty performing and/or can perform only with pain. If not applicable to you, please leave blank.
Housework
Yardwork
Personal Grooming
Travel
General
We invite you to discuss any questions regarding our services with us. The best services are based on a friendly understanding between provider and patient. PLACEHOLDER

Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges, and other expenses incurred in collecting your account.

 

I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims.

 

I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

INFORMED CONSENT FOR CHIROPRACTIC TREATMENT AND CARE

I hereby request and consent to the chiropractic services of Ace Chiropractic Clinic, associated licensed doctors, and/or authorized persons who might now or in the future treat me while employed by, working or associated with, or serving as backup for Ace Chiropractic Clinic in an attempt to improve my physical condition.

I understand the purpose of this and subsequent visits is to acquire chiropractic care. A natural and conservative approach to my health needs, chiropractic care utilizes manipulation or joint adjustments, exercise, nutrition, and various modes of physiotherapy. I understand that a definitive diagnosis may require further tests (x-ray, laboratory test, MRI, etc.) and/or referrals to other health care professionals. Although Ace Chiropractic Clinic may prescribe or suggest these tests or referrals, it is my responsibility to schedule an appointment and to acquire these tests and/or referrals. I understand and am informed that some risks are associated with chiropractic treatment, including, but not limited to, sprains, dislocations, fractures, disc injuries, stroke, burns, frostbite, and paralysis. I do not expect Ace Chiropractic Clinic to be able to anticipate and explain all risks and complications, but based on the facts then known, I wish to rely on his judgment during the course of the procedures, which he feels is in my current best interests. The body's (nervous and musculoskeletal systems) reaction to Ace Chiropractic Clinic treatments may be generalized soreness over and around the area of chief complaint. This is a normal and expected result because the muscles in the area have been stressed (spasm) and the bones are misaligned. During my treatment, Ace Chiropractic Clinic will be releasing stress on the spine, bones, joints, and surrounding soft tissue (e.g. muscles, tendons, ligaments, bursae, and nerves). This process breaks up the pain and spasm cycle in the body, but in doing so, my body may require time to adjust to these physiological changes. I understand that I am responsible for monitoring my own condition throughout the treatment and will inform Ace Chiropractic Clinic of any unusual symptoms that may occur. In signing the informed consent form, I affirm that I have read this form entirely and that I understand the nature of the chiropractic treatment. I also affirm that all my questions regarding chiropractic treatment, the management of my case, and the related risks of chiropractic treatment have been answered to my satisfaction.

I intend this consent form to cover the entire course of treatment for my present condition and for any future condition for which I seek treatment.

CHIROPRACTIC INFORMED CONSENT TO TREAT

I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, and any supportive therapies on me (or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic indicated below and/or other licensed doctors of chiropractic and support staff who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic name below, including those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office of clinic personnel the nature and purpose of chiropractic adjustments and procedures. I understand that results are not guaranteed. I understand and am informed that, as in the practice of medicine and like all other health modalities, results are not guaranteed, and there is no promise of a cure. I further understand and am informed that. As in the practice of medicine, in the practice of chiropractic, there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations, and sprains. I do not expect the doctor to be able to anticipate and explain all the risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, in my best interests.

I further understand that there are treatment options available for my condition other than chiropractic procedures. These treatment options include, but are limited to self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants, and painkillers; physical therapy; steroid injections; bracing and surgery. I understand and have been informed that I have a right to a second opinion and to secure other opinions if I have concerns as to the nature of my symptoms and treatment options.

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.

ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: it is understood that any dispute as to medical malpractice, that is as to whether any medical service rendered under this contract were unnecessary or unauthorized or were unauthorized, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: it is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouses of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a backup for the health care provider, including those working at the health care providers clinic or office or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care providers associates, association, cooperation, partnership, employees, agents, and estate must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator within thirty days and a third arbitrator shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party's pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees or other expenses incurred by a party for such party's own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request of the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would be a proper additional party in a court action, upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (civil code 3333.1) the limitation on recovery for non-economic losses (civil code 3333.2) and the right to have a judgment for future damages conformed to periodic payments (ccp 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to the arbitration agreement.

Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the application legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: the agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: if the patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here._____ Effective as the date of first professional services. If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE; BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com

Office Hours

Monday:

8:00 am-7:00 pm

Tuesday:

8:00 am-7:00 pm

Wednesday:

8:00 am-7:00 pm

Thursday:

8:00 am-7:00 pm

Friday:

8:00 am-7:00 pm

Saturday:

Closed

Sunday:

Closed

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