Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net

Welcome to Clearview Chiropractic Life Center! Please read this carefully so you will know what to expect during your first 2 visits. Over 90% of our new patients are referred by current members of our practice, which means the world to us!  We look forward to sharing the Chiropractic Lifestyle and How to Get Well & Stay Well with you and your family!

 What to Expect at Clearview Chiropractic Life Center

 Day 1: Consultation & Exam

  •  Today’s visit should take approximately 40 minutes
  • Personal Consultation with the Doctor, Complete Biomechanical Exam, and if necessary X-rays will be performed to help the Doctor know exactly how to best help you.

  • We will discuss your health history to fully understand your current condition as well as to discover hidden events or lifestyle choices that may be impacting your health

  • All fees will be discussed with you in advance. We require payment for today’s services at the end of the appointment

  • At checkout, you will need to schedule your Doctor’s Report

Day 2:  Doctor’s Report and Best Recommendations

  •  You will be given a specific description of the condition of your spine and nervous system and how these findings impact your current and future health
  • The beginning portion of this report may be in a group setting, so please arrive on time. All of your personal information is discussed in private with the Doctor.

  • The Doctor’s report details the solutions available to maximally correct your problems. If Subluxation is confirmed, your first adjustment will be recommended on this visit.

  • This report is scheduled on very specific days/times, and takes approx. 45 mins -1 hour

  • A financial decision regarding your care will need to be made at this time.

Please bring your spouse/significant other if possible. It is critical to the success of your case that your spouse/significant other sees and understands this information so they are able to support you through this process. (A work excuse can be provided if needed for you or your spouse/significant other).

 

Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
First Name
Last Name
Address
City
Zip Code
Gender
SSN
Date of Birth
Height
Weight

Parent/Guardian

First Name
Last Name
Home Phone
Email
Cell Phone
How did you hear about us?
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
Cigarette/alcohol use during pregnancy?
Location of birth:
Birth intervention performed:
Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
Birth Length
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Name of Pediatrician
Date of Last Visit
Reason
Treatment
At what age, in months, was the following introduced?
Solids:
Cows milk:
At what age was your child able to (in months):
Respond to sound
Hold head up
Crawl
Sit



Respond to visual stimuli
Stand Alone
Walk Alone


Personal Illness History
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Vaccination history
Family history
Please list any vitamins, herbs, or minerals the child takes:
Childhood Diseases
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
Number of doses of other prescription medications your child has taken:
Last 6 months: Since birth:
Child's daily habits (skip any questions that do not apply):
Hours of sleep per night (1-24)
Child's exercise
Average amount of time spent watching TV, playing video games, or using a computer per day:
How often does this child consume:
Caffeine Drinks:
Sugars/sweets:
Dairy Products
Wheat Products
Fruits/Vegetables
Water as a beverage:

Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Present problem:
First occurrence of condition
Did something specific cause this condition? (please describe)
Since the problem started, is it:
Does anything make it better?
Does anything make it worse?
Other health professionals seen for this problem (please list names and dates if applicable)
Chiropractor
Medical Doctor
Other
Clearview Chiropractic
5417 Acton Hwy Suite 101
Granbury, TX 76049
(817) 326-1174
office@clearviewchiropractic.net
Please read the following carefully before signing.

The statements made on this form are accurate to the best of my recollection and I agree to allow this office to examine me for further evaluation. I understand that I am responsible for all payment of fees charged in this office of services rendered.

Privacy Act: I consent to the use of my protected health information by Dr. Robertson for the purpose of analyzing, diagnosing or providing treatment to me, obtaining payment for my health care bills or conduct health care operations. I understand that the Notice of Privacy Practices is posted on www.clearviewchiropractic.net and in the office at the front desk, and I may request a written copy. HIPAA Compliance.

TERMS OF ACCEPTANCE:

When a patient seeks chiropractic care and we accept a patient for such care, it is essential for both to be working for the same objective.

Chiropractic has only one goal. It is important that each patient understands both the objective and the method that which will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: The adjustment is the specific application of forces to facilitate the body’s correction of a vertebral subluxation. Our Chiropractic method of correction is by specific adjustments to the spine.

Health: The state of optimal physical, mental, and social well-being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer the diagnosis or treatment of any disease. We only offer to diagnose either vertebral subluxation complex and/or neuro-musculoskeletal conditions. However, if during the course of a chiropractic spinal examination we encounter unusual finding which are outside the scope of practice for a Doctor of Chiropractic, we will advise you. If you desire advice, diagnosis, or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatments prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate major interference to the expression of the body’s innate wisdom. Our only method is the specific adjustment to correct vertebral subluxation. And we may use other procedures to help your body hold those adjustments.

 

* Please read and agree to the terms
Relationship to patient
Signature
Today's Date: 21 Sep 2017