Bow Valley Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.
- If you do not already have AdobeReader® installed on your computer, click here to download.
- Download the necessary form(s), print it out and fill in the required information.
- Bring it with you to your appointment, email it to us [email protected] , or fax - 403.262.2207 - us your printed and completed form(s).
New Patient Health History Form - Required
This lets us know the history and current state of your health.
For a better understanding of your situation and to help you, Bow Valley Chiropractic will need to collect some health-related personal information about you. If needed, this information may be shared with other medical practitioners as it pertains to your care. Our clinic’s Notice of Privacy Practices is in accordance with Alberta’s Health Information Act.
Your Protected Health Information contains identifiers like your name, personal health number, address, medications used, or other information that reveals who you are. Your records at the clinic display your personal health information. We understand that your health information is personal to you and we are committed to protecting it.
Use and Disclosure of Protected Health Information
Dr. Kim and his staff are legally required to maintain your personal health related information confidential. Our office has policies, procedures and other safeguards in place that protect your Personal Health Information from improper use and disclosure. These policies are described in further detail below:
Treatment: If necessary, medical information may be shared with other healthcare providers directly involved in patient care. For example, a referral to a specialist will require the disclosure of Personal Health Information.
Appointment and Patient Recall Reminders: Personal Health Information may be used to contact patients as a reminder of a scheduled appointment.
Payment: Personal Health Information may be used and disclosed to extended health insurance companies on the patient’s behalf for the purposes of payment for services (Direct Billing).
Lawsuits and Other Legal Disputes: Personal Health Information may be used and disclosed to respond to a court or administrative order, a subpoena, or a discovery request, or to defend any lawsuit arbitration.
Other Uses and Disclosures: Release of Personal Health Information in situations not covered by this notice will occur only with your written permission unless it can be reasonably inferred from the statements above.
Revoking Permissions: Permissions to share Personal Health Information may be revoked in writing at any time. We are unable to take back any previous disclosures made when previous permissions were in effect.
Bow Valley Chiropractic,
Calgary, Alberta, Canada