In Motion Therapy

Phone: 925-292-5850
inmotionsportschiro@yahoo.com
2165 4th Street
Livermore, CA 94550

Patient Information

Sex : Male Female

Who is Responsible for your bill:

Employment Information

Emergency Information

Current Health Condition

Medications, Herbs, Supplements

Lifestyle

Tobacco Yes No

Recreational Drugs ? Yes No

Past Health History

Please report any past health conditions that may affect a proper diagnosis.

Major Surgeries or Operations:

Yes No If yes explain ?

Broken Bones:

Yes No If yes explain ?

Major falls or accidents:

Yes No If yes explain ?

Hospitalizations:

Yes No If yes explain ?

Previous Chiropractic care:

Yes No Name Of Doctor ?

Review of Systems

(Check all that apply)

Females Only

Is there a possibility that you might be pregnant ? Yes No

Consent for Treatment and Insurance Authorization

I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of Chiropractic at In Motion Sports and Family Chiropractic. I hereby assign benefits and I Understand that payment is due as services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company(excluding contractual allowance).if, after 60 days, insurance payment has not been received. I understand that the charges are my responsibility and payable immediately. Additionally, I consent to treatment as deemed necessary by the Doctor of Chiropractic at In Motion Sports and Family Chiropractic

Patient Agreement Forms

I Acknowledge, I have seen, I have access to, and agree to :

Consent For Treatment    View Form

Notice of Privacy Practice     View Form

In Motion Fee Schedule     View Form