Abraham Kozma, D.C., P.A.

2801 Fruitville Rd. Suite 180 Sarasota, Florida 34237

Office 941-924-9892 Fax 941-924-7283
www.sarasotaclinic.com

Patient Data
First Name Last Name Date Email*
* Your email will NOT be shared with any 3rd parties, and is used for occasional office announcements and promotions.

Mailing address
Address City State Zip
Telephone (Work) (home) Referred By
Age Birth Date Social Security # Number of Children
Occupation Employer
Marital Status Spouse's Name Spouse's Occupation
Spouse's Employer Spouse's Health Status
Emergency Contact Phone

Current Complaints
Nature of Injury: Automobile* Work Other

Please describe:

Date of Injury Date symptoms appeared

Have you ever had same condition? No Yes If yes, when?

List of other practitioners seen for this injury/condition

Have you ever been under chiropractic care? No Yes

If yes, please describe

Insurance Information

Name of party responsible for payment Phone

Do you have health insurance? No Yes, Name of company
* If an auto accident, please provide:
Insurance Company Name Contact Person
Phone: Claim #

Signatures
Name of the insured ________________________________________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance
carrier and myself. I understand and agree that all services rendered to me and charged are my personal
responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for
professional services rendered to me will be immediately due and payable.
Patient’s signature _______________________________________________ Date ____________________
Spouse’s or guardian’s signature __________________________________ Date ____________________
Medical History
Have you been treated for any conditions in the last year? No Yes
If yes, please describe
Date of last physical exam Is there a chance that you are pregnant? No Yes
Have you had X-rays taken? No Yes If Yes, where?
What medications are you taking and for what conditions (Please list dosage and amounts, etc)l

What vitamins, minerals, or herbs do you currently take? (Please list for what conditions, dosage, and frequency).

Have you ever: No Yes Briefly Explain

Broken bones?
Been hospitalized?
Been in an auto accident?
Had Sprains/Strains?
Been struck unconscious?
Had surgery?

Family History
Family Members - Present and past health conditions (Example: heart disease, cancer, diabetes, arthritis, etc.)

Do you experience pain every day? No Yes

Do your symptoms interfere with daily life? No Yes
Does pain wake you up at night? No Yes
Are your symptoms worse during certain times of the day? No Yes
Do changes in weather affect your symptoms? No Yes
Do you wear orthotics? No Yes
Do you take vitamin supplements? No Yes
What activities aggravate your symptoms?

Habits None Light Moderate Heavy

Alcohol
Coffee
Tobacco
Drugs
Exercise
Sleep
Appetite
Soft Drinks
Water
Salty Foods
Sugary Foods
Artificial Sweeteners
 Abraham Kozma, D.C.
2801 Fruitville Rd. Suite 180 Sarasota Florida 34237-5357
Office 941-924-9892 Fax 941-924-7283
www.sarasotclinic.com

AUTHORIZATION FOR TREATMENT AND CONSENT FOR CARE

I hereby voluntarily consent to chiropractic care and/or diagnostic treatment by Sarasota Chiropractic,
Physical Therapy & Massage, its physicians and employees as explained to me by the attending physician
and whomever he/she may designate as their assistant. I am aware that the practice of chiropractic is not an
exact science and that any procedure has an inherent risk. I acknowledge that no guarantees can be made to
me as a result of any treatment or examination in this office.

I understand and agree that I am personally responsible for payment of all services rendered. Health and
accident policies are an arrangement between an insurance carrier and myself, however, Sarasota
Chiropractic, Physical Therapy & Massage may accept certain insurance assignments of benefits. The
acceptance of insurance assignment is individually determined and prior authorization is required. I
understand that upon termination of care, any outstanding charges for professional services rendered will be
immediately due and payable. Fees incurred for any account turned over to a third party for the purpose of
collections on your account is the patient’s financial responsibility.

Patient Signature: ____________________________________________________ Date: _____________

Relationship, if Guardian: ________________________________________________________________

ALL FEMALE PATIENTS PLEASE COMPLETE THIS SECTION

In order to protect you, the patient, we need to be assured that if the Doctor orders x-rays, there is no
possibility of you being pregnant.

I hereby release Sarasota Chiropractic, Physical Therapy & Massage and the staff from any responsibility for
injury or complications to my fetus or myself should I be pregnant on this date.

______ There is a possibility of my being pregnant.

______ There is NO possibility of my being pregnant.

Signature of Patient ____________________________________________________ Date: ____________

Relationship, if guardian: __________________________________________________________________

 Abraham Kozma, D.C., P.A.
2801 Fruitville Rd. Suite 180 Sarasota, Florida 34237
Office 941-924-9892 Fax 941-924-7283
www.sarasotaclinic.com

PATIENT CONSENT TO RECEIVE MAIL AND /OR TELEPHONE MESSAGES

PATIENT NAME: _____________________________________________________________

DO WE HAVE YOUR PERMISSION TO:

Send an appointment reminder to your home? Yes No

Send test results to your home? Yes No

Leave the following information on your home answering machine/voice mail:

Appointment Information: Yes No

Billing Information: Yes No
Medical Information: Yes No

I give permission to share appointment information with the person(s) named below:

Name: _______________________________________________________
Name: _______________________________________________________

I give permission to share medical information with the person(s) named below:
Name: _______________________________________________________
Name: _______________________________________________________

I give permission to share billing information with the person(s) named below:
Name: ________________________________________________________
Name: ________________________________________________________

Signature of Patient ____________________________________________________

Date: ________________________________________________________________
 Abraham Kozma, D.C.
2801 Fruitville Rd. Suite 180 Sarasota Florida 34237-5357
Office 941-924-9892 Fax 941-924-7283
www.sarasotclinic.com

ACKNOWLEDGMENT OF RECEIPT
OF
NOTICE OF PRIVACY PRACTICES

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read
them or declined the opportunity to read them and understand the Notice of Privacy Practices. I
understand that this form will be placed in my patient chart and maintained for six years

_________________________________________ __________________________________
Patient Name (Please Print) Date

_________________________________________
Parent, Guardian or Patient’s legal Representative

_________________________________________
Signature

THIS FORM WILL BE PLACED IN THE PATIENT’S CHART AND MAINTAINED

FOR SIX YEARS.
List below the names and relationship of people to whom you authorize the Practice to release PHI
_______________________________________ ________________________________
_______________________________________ ________________________________
_______________________________________ ________________________________
 Abraham Kozma, D.C.
2801 Fruitville Rd. Suite 180 Sarasota Florida 34237-5357
Office 941-924-9892 Fax 941-924-7283
www.sarasotclinic.com

Financial Policy
Sarasota Chiropractic, Physical Therapy & Massage is covered under many insurance plans. Most of our
patients that have health or accident insurance will fall under one of the plans discussed in this policy. We ask
that you read and understand our policy as it applies to your particular situation.

PATIENTS WITHOUT INSURANCE

We request that 100% of your visits be paid at the time of the visit. We are happy to accept payment
with cash, check, credit card (no Diner’s club) and PCD.

“ON THE JOB” INJURY (Worker’s Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation
Insurance. You will need to inform your employer of the accident and obtain their permission to be seen
at our office along with the name and address of their insurance carrier and your claim number.
Without an authorization or referral to be seen here, we are not able to treat you.

PERSONAL INJURY OR AUTOMOBILE ACCIDENTS

Please notify YOUR auto insurance carrier of the accident immediately. Even if you were not at fault as
Florida is a no-fault state. If or when you retain legal representation (an attorney), please notify our office
immediately. Although you are ultimately responsible for your bill, we will wait for settlement of your claim
after your care is completed if you have an attorney. Once the claim is settled or if you suspend or
terminate care, any fees for services are due immediately by you as the patient.

MANAGED CARE PLANS/ GROUP OR INDIVIDUAL INSURANCE – such as

[BC/BS, CIGNA, MEDICARE, TPA, UNITED HEALTH CARE and others]
Our office is on many different insurance provider lists. Please inquire about these plans at our front desk. As
soon as possible, we will call to verify benefits on your insurance. However, the benefits quoted to us by your
insurance company are not a guarantee of payment. You are required to pay your co-pay and/ or
deductible as required by the contract between you and your insurance company. Payment will be due
by you at the time of service for any non-covered services, deductibles or co-pays.

I have read and understand this financial policy for the Sarasota Chiropractic, Physical Therapy and Massage
office. I understand that my insurance is a contract between myself and my insurance company and this office.
I understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule of
care as prescribed by the doctors of this office, those fees will be due and payable immediately by myself as
the patient.

Patient’s signature (or guardian if patient is a minor) Date

Front Desk Witness _________________________________________________ Date ___________________

 PATIENT TREATMENT RECORD

Patient’s name: Date of birth:

Phone: Email:

You are scheduled for a series of non-invasive treatments with the EMSCULPT NEO®.
EMSCULPT NEO is indicated to be used for:
• Improvement of abdominal tone, strengthening of the abdominal muscles, development of firmer abdomen.
• Strengthening, Toning and Firming of buttocks, thighs, and calves.
• Improvement of muscle tone and firmness, for strengthening muscles in arms.
• Non-invasive lipolysis (breakdown of fat) of the abdomen.
• Reduction in circumference of the abdomen.
• Non-invasive lipolysis (breakdown of fat) of the thighs.
• Reduction in circumference of the thighs.
• EMSCULPT NEO is intended for use with skin types I – VI.
• Non-invasive lipolysis (breakdown of fat) of the flanks limited to skin types I - IV.
• Non-invasive lipolysis (breakdown of fat) of the upper arms limited to skin types II and III and BMI 30 and
under.
The EMSCULPT NEO device is intended to be used under medical supervision for adjunctive therapy for the
treatment of medical diseases and conditions.
The EMSCULPT NEO device is indicated for use in stimulating neuromuscular tissue for bulk muscle excitation
in the legs or arms for rehabilitative purposes.
Indications for Use for Muscle Stimulators:
• Relaxation of muscle spasms
• Prevention or retardation of disuse atrophy
• Increasing local blood circulation
• Muscle re-education
• Immediate post-surgical stimulation of calf muscles to prevent venous thrombosis
• Maintaining or increasing range of motion
Initials: _____

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105
Please indicate your primary treatment goal:
☐ Sculpting
☐ Functional Wellness

Your treatment provider will discuss your specific treatment needs. The recommended number of treatments is
four. Each treatment typically lasts about 20 to 30 minutes per session, with sessions separated by 5 to 10 days
for the HIFEM+RF Advance/Gentle/Function preset or 2 to 3 days for the HIFEM Classic/Function preset.
Completing a full treatment series is necessary to maximize treatment efficacy. You may need additional
treatments depending on your goals.

Initials: _____

No unusual preparations are required before the treatment; however, it is strongly recommended to keep your
body well-hydrated. On the day of the treatment, it’s advisable to wear comfortable clothing that allows flexibility
for proper positioning during the procedure. To prevent excessive sweating, the treatment area should be shaved
or the hair trimmed beforehand. The treated area will also be wiped with alcohol wipes before the treatment to
remove any moisture, perfume, moisturizers, or oils. You will be asked to remove all metallic accessories and
electronic devices.

Initials: _____

I acknowledge that smoking, excessive alcohol consumption, eating disorders, and certain medications may affect
the success of the treatment outcome. While no special diet is required, maintaining a healthy diet is encouraged
to help promote and sustain results.

Initials: _____

The treatment does not require anesthesia. During the procedure, you may feel intense muscle contractions and
a warming sensation in the treated area. It’s important to note that while the warming sensation may be intense,
it should never be painful. If you experience any pain or discomfort, please ask your provider to adjust the intensity.
The procedure requires no recovery time, and you can typically return to your daily routine immediately afterward.

Initials: _____

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105
 I am aware that I MUST NOT wear any metallic accessories (such as jewelry, watches, or clothing with metallic
threads or accessories) during the treatment. I also confirm that I do not have any metallic or electronic implants
(such as pacemakers, defibrillators, metallic IUDs, etc.).

Initials: _____

Please answer whether you currently have or had any of the following in the past*:

▪ Electronic implants (such as cardiac pacemakers, defibrillators and neurostimulators) ☐ YES ☐ NO

▪ Metal implants ☐ YES ☐ NO

▪ Drug pumps ☐ YES ☐ NO

▪ Malignant tumor ☐ YES ☐ NO

▪ Pulmonary insufficiency ☐ YES ☐ NO

▪ Muscles in acute phase of injury ☐ YES ☐ NO

▪ Cardiovascular diseases ☐ YES ☐ NO

▪ Disturbance of temperature or pain perception ☐ YES ☐ NO

▪ Hemorrhagic conditions ☐ YES ☐ NO

▪ Septic conditions and empyema ☐ YES ☐ NO

▪ Acute inflammations ☐ YES ☐ NO

▪ Systemic or local infection such as osteomyelitis and tuberculosis ☐ YES ☐ NO

▪ Contagious skin disease ☐ YES ☐ NO

▪ Elevated body temperature ☐ YES ☐ NO

▪ Pregnancy, postpartum and nursing period ☐ YES ☐ NO

▪ Graves’ disease ☐ YES ☐ NO

▪ Metallic IUD ☐ YES ☐ NO

▪ Recent surgical procedures (muscle contraction may disrupt the healing) ☐ YES ☐ NO

▪ Areas of the skin which lack normal sensation ☐ YES ☐ NO

*For the full range of contraindications, warnings, and cautions, consult your treatment provider.

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105
If you answer YES to any of these questions, please specify:

_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________

Treatment considerations

▪ I am aware that the treatment cannot be applied over the head, neck, spinal cord, heart, or testes.

Initials: ______

▪ I am aware that the treatment cannot be applied over swollen or neoplastic tissues, space-occupying lesions,
or skin eruptions.

Initials: ______

▪ I am aware that pregnancy is contraindication, and pregnant women cannot undergo the treatment.

Initials: ______

▪ I am aware that with any heat-based therapy, in rare cases, burns can occur.

Initials: ______

▪ I am aware that the applicators must always be in direct contact with the skin. I am aware that treatment
must not be applied over clothing or scar tissue.

Initials: ______

▪ I understand that there are certain side effects associated with EMSCULPT NEO treatments. The side effects
may include, but are not limited to muscular pain, intramuscular fat decrease, temporary muscle spasm,
temporary joint or tendon pain, local erythema or skin redness, increased menstrual flow in female patients
and panniculitis.

Initials: ______

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105
 ▪ I understand that the treatment over muscles in the acute phase of injury is contraindicated.

Initials: ______

▪ I understand that the treatment may involve risks of complications or injury from both known and unknown
causes, and I freely assume these risks.

Initials: ______

▪ I agree to before and after treatment photographs, measurements, and weighing, as this will aid in the
medical evaluation of the results of the treatment. This information will be collected for medical records or
marketing purposes.

Initials: ______

▪ I understand results may vary from person to person and that an exact result cannot be predicted. Completing
a full treatment series is necessary to maximize treatment efficacy. It is very unlikely, but I acknowledge that
it is possible not to experience any noticeable results after the procedure. I understand that the results may
not meet my expectations.

Initials: ______

▪ I certify that I have read this entire document and agree with all provisions. I certify that I have had the
opportunity to ask questions and these questions have been answered in full to my satisfaction.
I fully understand the treatment conditions, the procedure, and possible side effects.

Initials: ______

▪ I have read the above information, and I request and give my consent to be treated with the EMSCULPT
NEO by the physician(s) at this practice and their designated staff.

Initials: ______

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105
 My signature below indicates that the above information is accurate and current.

Patient’s signature: ______________________________________ Date: ___________________________

Witness (in print): ________________________ Signature: ___________________ Date: ___________

Practice Name: ____________________________

THIS FORM IS ONLY A SAMPLE AND IS BEING PROVIDED TO BTL CUSTOMERS SOLELY FOR THE PURPOSE OF ENCOURAGING BTL
CUSTOMERS TO DISCUSS THE USE OF SUCH A FORM WITH THEIR ATTORNEY. BTL INDUSTRIES DOES NOT REPRESENT OR
WARRANT THE LEGAL SUFFICIENCY OR ENFORCEABILITY OF THIS SAMPLE CONSENT.

Emsculpt_Neo_CLIN_General_Patient_Record_ENUS105