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.
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:
HEALTH & HISTORY QUESTIONNAIRE:
Please list the main 3 reasons you are seeking our help::
How often are your symptoms present?
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.
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.
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.