Chiropractic Healing Center – Eugene Chiropractor | Eugene ...



CHIROPRACTIC HEALING CENTER

492 E 13th Ave. Suite 200

Eugene, OR 97401

Ph: (541)342-4520 F: (541)485-7102

Laura Adams, DC | Kal Welch, DC

Pam Skeele, LMT, CA | Jude Painton, LMT, CA | Kassandra Olsen, LMT, CA

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PATIENT REGISTRATION

Today’s Date _______________

Name______________________________________ Date of Birth________________Age ______

Address ________________________________________ Home Phone _____________________

City ______________________ State_____ Zip_________ Cell Phone _____________________

F__ M__ E-mail___________________________________ Occasional Newsletter OK? Y/N

Employer ____________________ Occupation _________________ Work Phone _____________

Marital Status: S M W D P Spouse’s Name ______________________ # of Children ________

How did you hear about us? _________________________________________________________

Emergency Contact (name & phone): _________________________________________________

I am here today due to: __ Illness __ Trauma __ Work Injury __ Auto Accident __Other

What date did this occur? _______________

FOR INSURED PATIENTS ONLY

PRIMARY INSURANCE FOR TODAY’S VISIT: ___Private Ins. ___Auto ___WC ___Medicare

Ins. Co. & Address ________________________________________________________________

Name of Insured: ___________________________________ ID No: ________________________

Group No. ____________ Claim No. ___________________Medicare No. ____________________

SECONDARY INSURANCE: ___ Private Ins. ___ Auto ___ WC ___ Medicare

Ins. Co. & Address: ________________________________________________________________

Name of Insured: ___________________________________ ID No: ________________________

Group No. ____________ Claim No. __________________ Medicare No. ___________________

I understand that health insurance policies are an arrangement between my insurance carrier and myself. Billing is done by the Chiropractic Healing Center as a courtesy only and all services rendered to me are my personal responsibility.

I authorize the release of any medical information necessary to process my insurance claim and

I authorize payment of medical benefits to this office for professional services rendered.

Patient Signature________________________________________________ Date ______________

CHECK THE SYMPTOMS THAT YOU HAVE NOTICED IN THE LAST YEAR:

|[ ] Headache |[ ] Chest pain |[ ] Hand numbness |[ ] Muscle tension |[ ] Nervousness |

|[ ] Neck pain |[ ] Shortness of breath |[ ] Foot numbness |[ ] Shoulder pain |[ ] Irritability |

|[ ] Neck stiff |[ ] Loss of memory |[ ] Tingling in arms |[ ] Elbow pain |[ ] Anxiety |

|[ ] Upper back pain |[ ] Loss of balance |[ ] Tingling in hands |[ ] Hand pain |[ ] Sleep problems |

|[ ] Upper back stiff |[ ] Loss of smell |[ ] Tingling in legs |[ ] Hip pain |[ ] Fainting |

|[ ] Mid back pain |[ ] Loss of taste |[ ] Tingling in feet |[ ] Knee pain |[ ] Cold sweats |

|[ ] Mid back stiff |[ ] Ringing/buzzing |[ ] Hand weakness |[ ] Ankle pain |[ ] Constipation |

|[ ] Low back pain |[ ] Light sensitive |[ ] Foot weakness |[ ] Foot pain |[ ] Diarrhea |

|[ ] Low back stiff |[ ] Pain behind eyes |[ ] Cold hands |[ ] Fatigue |[ ] Heartburn |

|[ ] Jaw pain |[ ] Dizziness |[ ] Cold feet |[ ] Depression |[ ] Nausea |

If other, describe: __________________________________________________________________

________________________________________________________________________________

Purpose of this appointment: ________________________________________________________

________________________________________________________________________________

Is this appointment related to an accident or injury? [ ] No [ ] Yes, _________________________

________________________________________________________________________________

________________________________________________________________________________

What aggravates your condition? _____________________________________________________

What relieves your condition? _______________________________________________________

Is this condition: [ ] Constant [ ] Getting progressively worse

[ ] Comes and goes [ ] Getting progressively better

Other doctors seen for this condition: _________________________________________________

Have you ever been under chiropractic care? [ ] Yes [ ] No

Doctor’s Name: ____________________ Reason for previous treatment: _____________________

Have you been treated by a physician in the last year? [ ] No [ ] Yes, _______________________

________________________________________________________________________________

Do you take vitamins or minerals? [ ] No [ ] Yes, ______________________________________

Please list all medications: __________________________________________________________

________________________________________________________________________________

| |Heavy |Moderate |Light |None |Are you wearing? |

|Alcohol |[ ] |[ ] |[ ] |[ ] |[ ] Orthotics |

|Tobacco |[ ] |[ ] |[ ] |[ ] |[ ] Heel lifts |

|Coffee |[ ] |[ ] |[ ] |[ ] |[ ] Insoles |

|Exercise |[ ] |[ ] |[ ] |[ ] |[ ] Arch supports |

|Sleep |[ ] |[ ] |[ ] |[ ] | |

|Appetite |[ ] |[ ] |[ ] |[ ] | |

PAIN DRAWING

Name:______________________________________________ Date ________________________

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Mark as follows:

A = Ache B = Burning N = Numbness P = Pins & Needles

S = Stabbing O = Other – Describe __________________________________________________

Payment Policy

We require payment at the time of service. If you have private health insurance and we are billing them, you pay only your co-pay or co-insurance at the time of service (you must first meet the yearly deductible your insurance policy specifies). We offer a Time of Service Discount for paying in full if either you don’t have insurance coverage or you are billing your own insurance. We will give you the information and form needed to do your own billing.

In the case of personal injury (auto accident) and workers’ compensation claims, we will bill the entire amount of each visit to your insurance company. If your insurance company is not paying, or stops paying, you will have to pay for massage in full at the time of service. You will be issued a refund at the time we receive payment from your insurance company. The cost of supplies, supports or supplements not paid for by your insurance are your responsibility and we will ask you to pay for them once we’ve heard back from your insurance company.

If payment for any part of your treatment is denied by an insurance carrier you will assume full responsibility for payment and will pay independent of any appeal process with the insurance carrier to the extent allowed by law.

If you have any questions concerning our payment policy, please feel free to ask the person at the front desk.

Cancellation Policy

We require 24 hours notice for all cancellations. If you cancel with less than 24 hours notice, you will be charged 50% of the total charges for the visit. If you fail to keep your appointment and do not call to cancel, you will be charged IN FULL for the total visit. We send appointment reminders as a courtesy; it is your responsibility to remember and come to your appointments.

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I have read, understand and agree to the above payment and cancellation policies while utilizing the services of the Chiropractic Healing Center.

Signed: ___________________________________________ Date: ________________

I have read, understand and agree to the above payment and cancellation policies while utilizing the services of the Chiropractic Healing Center.

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