DMX Patient Form

Digital motion X-ray (DMX) at Lazar Upper Cervical, Ann Arbor. About 10 minutes.

How this form works. When you select Send, only your name, phone number and email go to our office, so our team can call you to schedule your DMX visit.

Your health answers are not sent over the internet. They stay on this device. After you send, save or print your completed form and bring it to your visit.

Prefer paper? Download the fillable PDF, fill it in on your computer or by hand, and bring it with you. Or call 734.274.5107.

1Patient information

Today's date

First name Last name

Date of birth Mobile phone Other phone

Street addressCityStateZIP

Yes, text me appointment reminders. I agree to receive text messages from Lazar Upper Cervical about my DMX appointment and my visits. Message frequency varies. Message and data rates may apply. Reply STOP to opt out, HELP for help. Optional, and not a condition of any purchase or of receiving care. See our Privacy Policy and Terms of Service.

Emergency contact RelationshipTheir phone

Primary care doctorOffice phone

Referring doctor, if anyOffice phone or fax

2Auto accident and medical payments (MedPay)

Fill this in only if the study is related to an auto accident and your auto policy has medical payments (MedPay) coverage.

Is this study related to an auto accident?

YesNo

Date of the accident

Auto insurance company

Company addressCityStateZIP

Company phoneCompany fax

Policy or claim numberAdjuster's nameAdjuster's phone

3Neck and back questionnaire

In your own words, what would you like the motion study to look at?

How long? YearsMonthsWeeks

Is this the first time?

YesNo

Did this start with an injury, such as a car accident, fall, sports injury or concussion?

YesNo

If yes, what happened and when?

X-rays, MRI or CT of your neck before?

YesNo

If yes, which and when?

Occupation

Mark where you feel symptoms right now: check the letters from the key next to each area.

A Ache
B Burning
N Numbness
P Pins and needles
S Stabbing
O Other

Where you feel it, and how
Area	A	B	N	P	S	O
Head
Jaw
Neck
Upper back
Mid back
Low back
Right shoulder
Left shoulder
Right arm or elbow
Left arm or elbow
Right hand or wrist
Left hand or wrist
Right hip
Left hip
Right leg or knee
Left leg or knee
Right foot or ankle
Left foot or ankle

Notes on the chart, such as what Other means for you

5Notice of Privacy Practices

Our Notice of Privacy Practices explains how your health information is used and shared, and your rights. Read it at app.lazaruppercervical.com/policies, or ask for a printed copy at the front desk.

I acknowledge that I have been offered Lazar Upper Cervical's Notice of Privacy Practices.

6Signature

I am signing as

The patientParent or legal guardian

Signature (type your full name) Date

Relationship to the patient, if not the patient

I agree that typing my name above is my electronic signature on this form, with the same effect as signing it by hand.

Send shares only your name, phone and email with our office. We text you only if you check the text box in section 1.

Thank you. We have your request.

Someone from our team will call you to schedule your DMX visit. Your health answers were not sent: please save or print your completed form now, and bring it with you.

Questions in the meantime? Call 734.274.5107.

1Patient information

2Auto accident and medical payments (MedPay)

3Neck and back questionnaire

4Consent for digital motion X-ray (DMX)

5Notice of Privacy Practices

6Signature

Thank you. We have your request.