Well of Life Center for Holistic Healthcare

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.

Please complete and submit the below form.

New Client Form

CLIENT INFORMATION:

INSURANCE/MEDICARE INFORMATION:

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.
By typing my name above, I authorize the Well of Life Center for Holistic Healthcare to perform chiropractic services knowing that there are no guarantees, as none have been expressed or implied. Typing my name in the box acts as my signature on this page and absolves any liability on behalf any therapists or chiropractors of the Well of Life Center or any of their assigns, at this present time or any time in the future.
Please click HERE to read our Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.

Pin It on Pinterest