Turtle Creek Wellness & Chiropractic

Address:
Phone:
Website:

3102 Oak Lawn Ave. Suite #205 Dallas, TX 75219
(214) 521-6868
www.turtlecreekwellness.com

Patient Information

Patient First Name: *

Patient Last Name: *

Patient Gender *

Male

Female

Patient Address *

Apartment/Suite *

City *

State *

Zip Code *

Patient Date of Birth (MM/DD/YYYY): * +

Patient Phone Number *

Social Security # *

Patient Email *

Family Doctor *

How were you referred to our office? *

If you are using insurance please fill out the following information. If self-pay move on to the emergency contact.

Patient Relationship to Insured: *

Self

Spouse

Child

Other Adult

Insured's First Name on Card: *

Insured's Last Name on Card: *

Insured's Date of Birth (MM/DD/YYYY): * +

Insurance Company: *

ID Number: *

Group Number: *

Emergency Contact

Name *

Phone Number *

Chief Complaint / Symptoms

Which best describes your problem area *

When did this problem begin? Do you know what caused it? *

Have you had this problem in the past *

Yes

No

Which best describes your sympotoms *

Have you ever had any of the following studies to your head, neck, mid-back, or low back? *

Have you seen any other health care providers for this condition? If yes, who and when? *

Please list any and all medication you are currently taking: *

If you are suffering from any other medical conditions please list: *

Electronic Consent & Signature

The Nature of chiropractic treatment: the doctor will use his heands or a mechanical devise in order to mobilize your spinal joints. You may feel a release or movement of that joint through it's physiological barrier to improve spinal joint motion. This release of motion often elcits an audible sound. Various ancillary procedures such as tempertaure therapy, electrical stimulation units, mechanical traction tables, etc may also be used to improve spinal joint functionality.

Possible Risks: As with all health care procedures, medications, or modalities, complications are possible following chiropractic mobilization. Complications may include fractures of bone, muscular strain, ligamentous sprain, dislocations of joints, or injury to intervertebral discs, nerves or spinal cord. Cerebrovascular injury or stroke couls occur upon severe injury to arteries of the neck. A minority of patients may notice soreness or stiffness after the first few days of treatment. The ancillary procedures could produce skin irritations, burns, or minor complications.

Probablity of Risks: The risks of complications due to chiropractic treatment are extremely rare and have been described as rare as complications arise from taking a single asprin tablet. The risk of cerebrovascular injury or stroke, has been studied an estimated to be at 1 in 1 million to one in 20 million, and can be further reduced by screening procedures. The probablity of adverse reaction to ancillary procedures is also considered to be extremely rare.

Risks of remaining untreated: Delay of treatment allows for adhesions, scar tissue and degenerative changes. These changes can irratate the central nervous sytem causing chronic pain cycles. It is proven delaying treatment can and will complicate the condition and make any furture rehabilitation more difficult.

Unusual Risks: I have had the following unusual risks of my case explained to me in aforementioned. I have read the explanation above concerning chiropractic treatment. I have fully evaluated the risks and benefits of undergoing treatment. I have had the opprotunity to read the above consent form in full. I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.

My consent is freely given. I understand I may reverse this consent at any time in writing, but any disclosures given in reliance on this prior consent will be permissible. *

I consent & agree to the terms above

I do not consent

Head	Neck	Mid-back
Low Back	Shoulders	Upper extremities
Hips	Lower Extremities

constant	frequent	intermittent	radiating
numbness	tingling	burning	shooting
stabbing	dull	achy	soreness
stiffness	throbbing

X-rays	MRI
CT scan	Bone scan
Other