PATIENT FORMS

New Patient Forms

Below you will find New Patient forms that you may fill-out online and/or download and fill-out by hand.  Please bring these forms with you for your first appointment.  All forms must be filled-out as completely as possible.

Filling out these forms before your scheduled appointment, will you save you 20 - 30 min.

Note: depending on your special circumstances, it may be necessary for you to fill out additional forms once you are at the office.

 

* HIPAA Practice Privacy Notice (For your review only)

The above link provides our patients with our HIPAA Practice Privacy Notice.  This is provided for your review; you do not need to bring this with you. Please read at your convenience.

1. Reception Form (Print and Sign)

Please sign the Reception Form. This form states that we have made available to you the above HIPAA Practice Privacy Notice.

2. General Patient Information (Print and Fill-out)

This form provides us with all of your contact information.  If you fill out the emergency contact section, please make sure to sign the permission so we my contact your emergency contact person.

3. Case History (Print and Fill-out)

This form tells us all about your past and present health status.  When finished filling out the form, please do not forget to sign and date the bottom of the second page.

Pain Scale Rating (For Your Use Only)

This form is to assist you in filling out your pain scale rating on the case history form.

4. Direct-Pay Polices (Read and Sign)

This form provides you with inform consent about our office policies and fees.  Please review and sign both pages.

Note about Fees: To see if you are eligible for a contractual discount, click "HERE".

It will take you to the Available Discounts Page.

5. Chiropractic Informed Consent To Treat (Sample Form)

(MUST READ BEFORE COMING TO OFFICE)

California has an Informed Consent Law requiring all Chiropractors to obtain written consent from patients and to personally review the form with patients before the patient signs the form.  This allows the patient the opportunity to ask their doctor questions about the risks and benefits of Chiropractic treatments.  A person may not be accepted as a patient unless the form is reviewed and signed.

To save time, please review this "non-executable" sample forms before your office visit.  

To help answer your questions about Chiropractic, Subluxations, risk factors and side effects we have attached additional information to the sample form.  You may also like to read the webpage "Chiropractic", which provides even more information about Chiropractic via select research abstracts.  Click on the above webpage link.

6. Arbitration Form (Read and Sign)

Due to California's Informed Consent Law, our office must now request all patients to sign an arbitration form before a person may be accepted as a patient or to continue treatment in our office.  Please review and sign.

7. Consent to Treat a Minor (Must sign if under 18 y/o)

This form only needs to be filled-out by a parent or guardian if the patient is less than 18 years of age.

By law, Dr. Giangiulio will not be able to consult with a Minor (person less than 18 years old) unless a Parent or Guardian completes this form.

FLEX-FIT FORMS:  Currently Service is not Offered - Do Not Download

Flex-FiT Forms are Currently Non-downloadable

Below you will find the needed Flex-FiT forms to start your membership.  Completing, these forms meet the legal minimum requirement to establish each Flex-FiT member a patient file with the Offices of Dr, Jack R, Giangiulio, D,C. - Please bring the completed forms with you.

1. General Contact/Patient Information (Print and Fill-out)

This form provides us with all of your contact information.  One form must be completed for each person associated with your membership.  When you fill out the emergency contact section, please make sure to sign the permission so we my contact your emergency contact person.

2. Flex-FiT Terms of Agreement (Read, Print and Sign)

This form is the Offices of Dr. Jack R. Giangiulio, D.C.'s Flex-FiT Membership Terms of Agreement. This form must be signed to participate.

3. Flex-FiT Waiver Form (Read, Print and Sign)

This is the "Waiver & Release of Liability, Assumption of Risk, Hold No Harm, & Course of Conduct Agreement" for both you and your minor dependent. This form must be signed to participate.

4. Minor Consent Form (Only if Under 18 y/o)

You must complete this form for each minor associated with your membership.  This form must be filled out and signed by a parent or legal guardian.

 

 

When you are ready to join - "Click the Button"

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