Hawaii Sports Chiropractic. LLC

320 Uluniu St. Ste 2
Kailua, Hawaii 96734
If Other Insrurance:

Current Symptoms or Complaints

Please list reasons for this visit: (0=none and 10=Severe)
  #  Please list reasons for this visit:   Date first noticed   Severity of symptom.   Symptom is present:


In the past week, how much has your pain interfered with:

0=no interference 10 = severely limits
  Household Chores

Please check all of the following that apply to you:

Family History:

High Blood Pressure
Heart Problems/Stroke
Rheumatoid Arthritis

Current Health Habits:

What type(s) of service do you desire?

Temporary relief of symptoms/pain control
Elimination of cause of problem,if possible
Maintenance/regular care to help maintain good health

I certify that the above information is complete and accurate. If the health plan information is not accurate, or if I am not eligible to receive a health care benefit through this provider, I understand that I am liable for all charges for services received. I agree to notify this doctor immediately whenever I have changes in my health condition or health plan coverage in the future. I understand that a quote of benefits is NOT a guarantee of payment and benefits are subject to change at any time. I understand that co-payments are to be paid at time of service. (INITIAL)

I understand that my chiropractor or Clinical Services Manager may need to contact my Primary Care Physician if my conditions need to be co-managed. Therefore, I give authorization to my chiropractor to contact my physician, if necessary. (INITIAL)

I understand and agree that health and accident policies are an arrangement between an insurance carrier and me. Furthermore, I understand that Hawaii Sports Chiropractic will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if my insurance carrier refuses to pay for services rendered to me for any reason, any balance on my account will be immediately due and payable. (INITIAL)

I understand that this clinic has a 24 Hour Cancellation Policy and that I may be charged the full amount of my visit for any appointments that are either missed or cancelled without 24 hours notice. (INITIAL)

I hereby request and consent to chiropractic adjustments and / or other chiropractic procedures by DR. Aren Viveiros and/or anyone working in this office authorized by him to perform such. I understand and am informed that, as in the practice of medicine and all healthcare, the practice of chiropractic carries some risks to treatment that include but are not limited to fractures, dislocations, and sprains. I do not expect the chiropractor to be able to anticipate and explain all risks and complications. I understand that results are not guaranteed. Further, I wish to rely on the chiropractor to exercise judgment during the course of the procedure which the chiropractor deems are in my best interests at the time, based upon the facts then known. I hereby give my consent for treatment.