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Patient Intake Form

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

About this Patient

About the Spouse 

Employer Information

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Experience with Chiropractic 

Awareness of Chiropractic Principles 
Were you aware that...

Doctors of Chiropractic work with the nervous system?*
Please select one option
The nervous system controls all bodily functions and systems?*
Please select at least one option
Chiropractic is the largest natural healing profession in the world?*
Please select one option
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*
Please select at least one option

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Habits & Conditions

Medications I Now Take:
Do you exercise regularly?*
Please select one option
Do you wear:
Health Conditions:

FOR WOMEN ONLY:

Authorization for Care

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Who should receive bills for payment on your account?*
Please select at least one option

Ownership of X-ray Films


It is understood and agreed that the payments to the Doctor for X-rays is for the examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time while I am a patient of this office.

Emergency Contact

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Nutrition and self-care are just two of the components in obtaining optimal wellness. 


Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Initial Consultation Form 


Overall frequency of complaint ( choose one)
Overall intensity of complaint (choose one)
If yes, please select the amount below that you feel your symptoms increase at work:

Missed Appointments 


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a $20.00 fee.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.


Office Fee Schedule and Financial Policy 





 Service                                                           Fee 
ConsultationNo Charge
Initial Exam/Computer Scans$50-$150
Dynamic Re-Exam/Computer Scans      $50-$75
X-Rays (Per View) $45
Adjustments$40-$65
Wellness Adjustment Plans $110-$280

Our experience has shown that it is wise to have an understanding with our clients as to our office policies and fees. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and w will do our best to help you.

Important: All clients are responsible for full payment for the first visit (unless other arrangements have been made in advance.)
Today's payment will be made by:*
Please select at least one option

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

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

Office Hours

Our Regular Schedule

Monday:

8:00 am - 1:00 pm

3:00 pm - 7:00 pm

Tuesday:

9:00 am

6:00 pm

Wednesday:

8:00 am - 1:00 pm

3:00 pm - 7:00 pm

Thursday:

9:00 am

6:00 pm

Friday:

8:00 am - 1:00 pm

3:00 pm - 7:00 pm

Saturday:

9am

12pm

Sunday:

Closed

Closed

Location

Find us on the map