PATIENT FEE SCHEDULE As of January 1, 2017

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1 TERMS OF ACCEPTANCE When a patient seeks chiropractic care and we accept such a patient for care, it is essential for both to be working towards the same objective. Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be able to attain it. This will prevent any confusion or disappointment. An adjustment is the specific application of forces to facilitate the body s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments to the spine. Health is a state of optimal physical, mental and social well being, not merely the absence of disease. Vertebral Subluxation is a misalignment of one or more of the joints of the body. This can cause an alteration of nerve function and interference of the transmission of nerve impulses, lessening the body s innate ability to maintain maximal health. ****We do NOT offer to diagnose any DISEASE or CONDITION, or treat any DISEASE, CONDITION or SYMPTOM other than the vertebral subluxation. (misalignment of your spine)**** However, if during the course of a chiropractic spinal evaluation, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body s innate wisdom, the nervous system. Our only method is specific adjusting to correct vertebral subluxation. If you fully understand the above information, please feel free to sign below and begin your paperwork. If you choose not to, please return paperwork to the front desk without completion. I, have read and fully understand the above statement. Any questions regarding the doctor s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept chiropractic care on this basis. Patient s Signature Date Witness PATIENT FEE SCHEDULE As of January 1, 2017 New Patient: $75.00 (Includes Adjustment if performed) Adjustment: $35.00 Children fee as follows when parent is seen on same day: Children 0-4: Free Children 5-12: $20

2 PATIENT CASE HISTORY If you have read the Terms of Acceptance and have agreed and signed the form you may proceed to fill out the remainder of this paperwork. Name: Have you traveled to West Africa or anywhere within Africa in the last 6 months? Address: City: State: Zip: YES NO Home Phone: - - Work Phone: - - Cell Phone: - - Address: Occupation: Date of Birth: Gender: Male - Female PARENTAL CONSENT TO EVALUATE AND TREAT A MINOR I, being the parent/legal/guardian of Hereby grant permission for my child to receive chiropracc care. WITNESS: List any Allergies: Animals Aspirin Bees Chocolate Dairy Dust Eggs Latex Molds Penicillin Ragweed/Pollen Rubber Seasonal Allergies Shellfish Soaps Wheat X-Ray Dye Other: List any Surgeries: Back Brain Elbow Foot Hip Knee Neck Neurological Shoulder Wrist Other: List ALL PAST History conditions: Ankle Pain Arm Pain Arthritis Asthma Back Pain Broken Bones Cancer Chest Pain Depression Diabetes Dizziness Elbow Pain Epilepsy Eye/Vision Problems Fainting Fatigue Foot Pain Genetic Spinal Condition Hand Pain Headaches Hearing Problems Hepatitis High Blood Pressure Hip Pain HIV Jaw Pain Joint Stiffness Knee Pain Leg Pain Menstrual Problems Mid-Back Pain Minor Heart Problem Multiple Sclerosis Neck Pain Neurological Problems Pacemaker Parkinson s Polio Prostate Problems Shoulder Pain Significant Weight Change Spinal Cord Injury Sprain/Strain Stroke/Heart Attack Other: List Type of Medications you are taking: Anxiety Muscle Relaxors Pain Killers Insulin Birth control Cardiovascular Allergy Seizure Other:

3 List your Family History: Arthritis Asthma Back Pain Cancer Depression Diabetes Epilepsy Genetic Spinal Condition High Blood Pressure Heart Problems Multiple Sclerosis Neurological Problems Parkinson s Polio Prostate Problems Stroke/Heart Attack Other: Have you had any auto or other accidents? No Yes Describe: Date of last physical examination: Do you smoke? No Yes Do you drink alcohol? No Yes - how many per day? Do you drink caffeine? No Yes - how many per day? Do you exercise? No Yes (what forms and how often): Main reason for consulting the office: Become pain free Explanation of my condition Learn how to care for my condition Reduce symptoms Resume normal activity level Achieve a higher level of nervous system health through Chiropractic. FOR WOMEN ONLY Are you pregnant? Yes No Do you have breast implants? Yes No Are you nursing? Yes No Do you experience painful periods? Yes No Do you have irregular cycles? Yes No Are you taking birth control? Yes No

4 SOME QUESTIONS TO HELP US HELP YOU Who referred you to this office? If we could only help you with one health problem, what would that be? What other health problem would you like us to help you with? How did these problems start? When did these problems begin? Have you had these problems before? What activities or hobbies have you been unable to do because of your problem Is it worse in the morning or at night (check one) Morning Night Do you ever have numbness, tingling or pain in the arms or legs? How often do you feel the pain and how long does it last? List any other doctors you have seen for the above problem. Do you get any dizziness (circle one)? Yes Do you have any heart, lung or stomach problems (circle one)? Yes No No Are you right or left handed? How tall are you? How little do you weigh? Name of previous chiropractor

5 AUTHORIZATION FOR CARE At our office, we have one simple goal we want to render the highest quality Chiropractic care at the lowest possible fee. In order to accomplish this goal, we have altered some of our business procedures to keep our fees reduced. Please read over these procedures below to understand how our office functions, and to decide if you wish to participate. If you have any questions, please direct them to the receptionist. You may choose to submit receipts to your insurance company or other third-party health care program, but payment for such services by insurance companies is neither implied nor agreed to by this office. We take NO RESPONSIBILITY for non-payment by insurance companies for services rendered at our office. Our office will not respond to any requests for paperwork for insurance purposes or even acknowledge insurance requests for information on any patients case. However, patients may have a copy of their records. No balances can be kept or run by patients at any time. All adjustment visits are paid immediately prior to, or immediately after service being rendered. Our office reserves the right to deny services to anyone for any reason, or if the doctor feels that the patient s health is not being best served. I wish to initiate care at this office. I have read and understand this form and agree to all terms. Name: Date: Signature: NOTICE OF PRIVACY POLICY Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosures for the purposes of treatment, payment or practice operations will be made only after obtaining your consent. You may request restrictions on your disclosures. You may inspect and receive copies of your records within 30 days with a request. You may request to view changes to your records. In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and it s staff. I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third party payers Conduct normal healthcare operations such as quality assessments and physicians certifications. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and or disclosed. Patient Name (Print): Signature:_ Date: