Chiropractic New Client Form - Well of Life Center

CLIENT INFORMATION:

Name *

Today's Date: *

Home Phone Number:

Cell Phone Number: *

Email *

Email

Confirm Email

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate: *

Age: *

Marital Status: *

Number of Children:

Occupation: *

Years on Job:

Work Phone Number:

Are you currently a client of The Well of Life Center? *

Yes
No

INSURANCE/MEDICARE INFORMATION:

Are you currently Medicare eligible or do you have Medicare Disability? *

Yes
No

If yes, which type:

I have managed Medicare
I have traditional Medicare

Please understand that Medicare regulations defining the criteria needed to justify chiropractic adjustments are specific. The Chiropractor is not able to see clients who have traditional Medicare. In addition, The Well of Life Center is not able to submit claims on your behalf and we do not provide insurance codes for Medicare reimbursement.

Is this an Auto Insurance case? *

Yes
No

If yes, please fill out the Accident Information and History forms. These may be obtained from the Client Advocate or front desk. The Well of Life Center is not a provider for any health care insurance program. You will receive a receipt of payment, but it will not include any insurance codes.

In Case of Emergency, please contact:

Emergency Contact Name: *

Emergency Contact Phone Number: *

Relationship: *

HEALTH & HISTORY QUESTIONNAIRE:

Please list the main 3 reasons you are seeking our help:

Reason #1:

How long have you had this?

Reason #2:

How long have you had this?

Reason #3:

How long have you had this?

Reason #4:

How long have you had this?

Additional Notes/Comments:

How often are your symptoms present?

Reason #1:

0-25%
26-50%
51-75%
76-100%

Reason #2:

0-25%
26-50%
51-75%
76-100%

Reason #3:

0-25%
26-50%
51-75%
76-100%

Reason #4:

0-25%
26-50%
51-75%
76-100%

Please check any/all of the following that apply to you:

Have you ever suffered a stroke? *

Yes
No

Date of Stroke:

Pregnancy: *

Yes
No

Number of pregnancies:

Number of births:

Abnormal weight:

Gain
Loss

Alcohol use: *

None
Mild
Moderate
Extreme

Tocacco use: *

None
Mild
Moderate
Extreme

Arthritis: *

Yes
No

Location of arthritis:

Lyme disease: *

Yes
No

Date of Lyme diagnosis:

Do you have a pacemaker? *

Yes
No

Could you be pregnant? *

Yes
No

Family History (check all that apply):

History of Accidents (broken bones, car accidents, hospitalizations, head injuries, etc.):

Surgeries (procedure, date):

Medications (medication and condition):

Additional notes:

AUTHORIZATION FOR CHIROPRACTIC SERVICES: *

I understand and consent to the following:

When a patient seeks Chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective. Our practice objective is to eliminate interference to proper function of the neuro-musculo-skeletal system by way of correcting misalignments of the articulations of the vertebral column and other structures and treating related conditions of the nervous system, for the ultimate goal of restoration and maintenance of health. Chiropractic does not offer to diagnose or treat any disease or medical condition. However, if during the course of a chiropractic examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire diagnosis or treatment of those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Possible effects that may occur from chiropractic treatment are as follows: muscle soreness and irritation, headache, pain, muscle spasm and stiffness. In rare instances, dizziness, nausea, and/or a temporary increase in symptoms may occur. I, the undersigned, a patient in this office, hereby authorize Charney Slater, D.C. M.S., (and whomever they may designate as their assistants) to perform chiropractic procedures as considered necessary on the basis of findings during the course of said treatment.

FINANCIAL AGREEMENT: *

I understand and consent to the following:

I agree to pay for services rendered to the above-mentioned patient as the charge is incurred and I understand and agree that I am personally responsible for payment of any and all services. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered me will be immediately due and payable.

RECORDS RELEASE: *

I understand and consent to the following:

Charney Slater, DC, MS are authorized to obtain, examine, and make copies of medical records, x-rays and reports pertaining to treatment of my condition. This authorization is valid until revoked in writing by me. A photocopy of this authorization and my signature has the same effect as the original.

Please click HERE to read our Agreement and Release of Liability form. Then, sign below. By signing, you are acknowledging that you have read and accept the terms and conditions.

Signature: *

Clear Signature

I have read the above authorizations and by signing agree.

Chiropractic Intake Form

Please understand the importance of keeping your appointments. We do have a 24 hour cancellation policy that is strictly enforced.

Please contact our Client Advocate if you have any questions or need additional information.

New Client Form

CLIENT INFORMATION:

INSURANCE/MEDICARE INFORMATION:

In Case of Emergency, please contact:

HEALTH & HISTORY QUESTIONNAIRE:

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