Workers Compensation Intake

1930 S Bascom Ave Suite 230, Campbell, CA 95008 

(408) 340-5055  |  LifeGiving-Chiro.com  |  [email protected]


New Patient Intake Form

Workers Compensation Patients

Please Read:

Workers Compensation Patients Must have Prior Authorization before scheduling a workers compensation appointment.

Our office must receive all medical records and prior authorization documentation prior to scheduling a workers compensation appointment.

Please make sure that all documentation is received by our office through your insurance carrier, your third party referral service or with your attorney. Our office will need to confirm authorization to treat a new patient under workers compensation with the patient's employer or workers compensation insurance carrier prior to the patient being seen by or doctors or by our therapists.

Please be on time for your reserved appointment time. 

New patient examinations with a doctor will need to be rescheduled if more then 15 minutes late. 

Massage therapy appointments will receive only the amount of time which remains in their original reserved appointment time when they arrive late.

24 Hours Advanced Notice is Required for Cancelation of an appointment. 

Patients will receive a Courtesy Reminder for their reserved appointment time 24 hours in Advance. Please respond to avoid rescheduling fee. 

Please bring Photo Identification with you for your initial visit in our office.

Thank you!

Personal Information


Health History

History Of Industrial Injury

Please check any conditions you currently have or have had:

HIPAA PRIVACY PRACTICES ACKNOWLEDGMENT

I acknowledge Life Giving Chiropractic's Notice of Privacy Practices and I also understand that my personal health information is protected by HIPAA and may only be disclosed for treatment, payment, or healthcare operations.

Thank you for taking the time to fill out this form.

Location

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Office Hours

Chiropractic

Monday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

Closed

Wednesday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

8:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Sunday

Closed

Massage Therapy

Monday

Closed

Tuesday

Closed

Wednesday

Closed

Thursday

10:00 am - 5:00 pm

Friday

10:00 am - 5:00 pm

Saturday

Closed

Sunday

Closed

Chiropractic

Monday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
Closed
Wednesday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Thursday
8:00 am - 12:00 pm 2:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Saturday
Closed
Sunday
Closed

Massage Therapy

Monday
Closed
Tuesday
Closed
Wednesday
Closed
Thursday
10:00 am - 5:00 pm
Friday
10:00 am - 5:00 pm
Saturday
Closed
Sunday
Closed