Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com

 

Welcome!

Thank you for trusting Stonebridge Chiropractic with your health.

 

In this practice, our commitment is to treat you like a member of our family while delivering exceptional healthcare services.  For your convenience and in order to save you time on your first appointment, our new patient forms are available online. Please complete these forms 24 hours prior to your scheduled appointment.

 

When you arrive for your first appointment, please bring Your Health Insurance Card & Photo Identification.

 

We recommend you dress comfortably or in loose fitting clothing, as the initial examination process will require moving the spine and body through a full range of motion.  If you have any questions, please call our office at so we can make your first experience a great one!

 

 

Thank you for choosing Stonebridge Chiropractic!  We look forward to being a vital part of your healthcare team.

 

Sincerely,

Dr. Andrew A. Oteo

Doctor of Chiropractic

 

Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
First Name
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City
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SSN
Date of Birth
Height
Weight

Parent/Guardian

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Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
Complications during pregnancy?
Ultrasounds during pregnancy?
Medications during pregnancy?
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Location of birth:
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Delivery medication?
Delivery complications?
Birth Weight
APGAR Scores
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Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
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
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Personal Illness History
Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
Vaccination history
Family history
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Childhood Diseases
Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
Number of doses of antibiotics your child has taken:
Last 6 months: Since birth:
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Last 6 months: Since birth:
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Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
Present problem:
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Stonebridge Chiropractic
7204 Main Street, Ste.200
The Colony, TX 75056
(469) 535-3800
info@StonebridgeChiro.com
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Informed Consent to Chiropractic Treatment

 

 The nature of chiropractic treatment: The doctor will use his/her hands or a mechanical device in order to move your joints.  You may feel a “click” or “pop,” such as the noise when a knuckle is “cracked,” and you may feel movement of the joint.  Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound or dry hydrotherapy may also be used.

 

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

 

Probability of risk occurring:  The risks of complications due to chiropractic treatment have been described as “rare,” about as often as complications are seen from the taking of a single aspirin tablet.  The risk of cerebrovascular injury or stroke has been estimated at one in one million to one in twenty million and can even be further reduced by screening procedures.  The probability of adverse reaction due to ancillary procedures is also considered “rare.”

 

Other treatment options which could be considered may include the following:

 

Over-the-counter analgesics.  The risk of these medications include irritation to stomach, liver and kidneys, and other side effects in a significant number of cases.

 

Medical care, typically anti-inflammatory drugs, tranquilizers and analgesics.  Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases.

 

Hospitalization in conjunction with medical care adds risk of exposure to virulent communicable disease in a significant number of cases.

 

Surgery in conjunction with medical care adds the risks of adverse reaction to anesthesia, as well as an extended convalescent period in a significant number of cases.

 

Risks of remaining untreated: Delay of treatment allows formation of adhesions, scar tissue and other degenerative changes.  These changes can further reduce skeletal mobility and induce chronic pain cycles.  It is quite probable that delay of treatment will complicate the condition and make future rehabilitation more difficult.

 

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Today's Date: 23 Nov 2017