0 = (No Pain) 10 = (Worst Possible Pain)

0 = (No Pain) 10 = (Worst Possible Pain)

I hereby certify that the statements and answers given on this form are accurate to the best of my knowledge and understand it is my responsibility to inform this office of any changes in my health. I agree to allow this office to examine me for further evaluation.

I acknowledge that Optimum Health Chiropractic's "Notice of Privacy Practices" has been provided to me.

I understand I have a right to review Optimum Health Chiropractic's Notice of Privacy Practices prior to signing this document. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Optimum Health Chiropractic.

The Notice of Privacy Practices for Optimum Health Chiropractic is also provided on request at the main administration desk of this office. The Notice of Privacy Practices also describes my rights and Optimum Health Chiropractic's duties with respect to my protected health information.

Optimum Health Chiropractic reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a copy be sent in the mail or asking for one at the time of my next appointment.