Chiropractic CenterChester Family

Full Name: ____________________________________________________________________ Today’s Date: __________________

Address: ___________________________________________________ City ________________ State _______ Zip ____________

Date of Birth: ______/______/______ SSN: _______-________-_______ Sex: ☐ Male ☐ Female

Cell #: ____________________ Home #: ____________________ Email: _____________________________________________

Relationship status: ☐ Single ☐ Married ☐ Separated ☐ Divorced ☐ Widowed ☐ Other________

Emergency Contact: (name & relation)____________________________________________________ (#)_________________

Employer: ____________________________________________________ Occupation: ________________________________________

Address of Employer: ___________________________________________ City _____________ State ______ Zip ________

Do you have health insurance? ☐ No ☐ Yes If yes, who is your carrier? ________________________________

Who can we thank for sending you to us? _______________________________________________________________________

☐ Facebook ☐ Internet ☐ Sign ☐ Word of Mouth ☐ Physician ☐ Existing Patient ☐ Other

Have you ever been adjusted by a Chiropractor? ☐ No ☐ Yes If yes, where? __________________________

If yes, what was the reason for the visit? ________________________________________________________________________

Describe Reason for Today’s Visit: ________________________________________________________________________________

_______________________________________________________________________________________________________________________

When did you first notice it? ______________________________ What do you think caused it? _______________________

What makes it worse or becomes difficult to perform:? ☐Driving ☐Walking ☐Sitting ☐Bending

☐Standing ☐Breathing ☐Coughing ☐Sleeping ☐Working ☐Exercising ☐Other __________________

Have you seen another doctor for this? ☐ No ☐ Yes If yes, how long ago? __________________________

Doctor or Practice Name: ______________________________________________________ Phone #: _________________________

Were x-rays or other imaging studies performed? ☐ No ☐ Yes

Type of Treatment/ Results: ☐Medication ☐Physical Therapy ☐Surgery ☐Other _______________________

______________________________________________________________________________________________________________________

Rate your pain TODAY: 1☐ 2☐ 3☐ 4☐ 5☐ 6☐ 7☐ 8☐ 9☐ 10☐

New Patient Intake

Chiropractic CenterChester Family

Do you exercise? ☐ No ☐ Yes If yes, what type and how often?______________________________________

What activities/sports do you participate in? ________________________________________________________________

What position(s) do you sleep in? ☐ Back ☐ Right Side ☐ Left Side ☐ Stomach

Hours per night? _______ Quality? ☐ Good ☐ Fair ☐ Poor

List all medications/supplements you are taking and why you are taking each one (including o.t.c.)

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

Have you ever had any surgeries? ☐ No ☐ Yes If yes, what type and when? _______________________

__________________________________________________________________________________________________________________

Do you smoke? ☐ No ☐ Yes, how much per day? ______________________

Do you consume liquor? ☐ No ☐ Yes, how much per week? ______________________

Do you consume coffee or caffeinated beverages? ☐ No ☐ Yes, how much per day? __________________

I certify that, to the best of my knowledge, the above information is complete and correct. I understand

that it is my responsibility to inform CFCC if I ever have a change in health.

I authorize CFCC to release/receive any information necessary to expedite insurance claims. I hereby

authorize CFCC to bill my insurance company directly for their services. I assign payment directly to

Chester Family Chiropractic Center of any insurance benefits otherwise payable to me. In the event I

receive payment from my insurance carrier, I agree to endorse any payment I receive over to CFCC for

which these fees are payable. I authorize the use of my signature on all insurance submissions.

Patient (or Guarantor) Signature______________________________________________________________ Date:__________

Guarantor’s Relationship to Patient________________________________________________________

New Patient Intake

Chiropractic CenterChester Family

Our Notice of Private Practices provides information about how we may use and disclose medical information about you.

As provided in our notice, the terms of our notice may change. If we change our notice, you may receive a revised copy.

I certify that I have been provided with a copy of Chester Family Chiropractic Center’s Notice of Privacy Practices. I have

had the opportunity to read the Notice of Privacy Practices. I understand that I may ask questions to CFCC if I do not

understand any information contained in the Notice of Privacy Practices.

Patient (or Guarantor) Signature_________________________________________ Date:__________

Guarantor’s Relationship to Patient______________________________________________________

It has been explained to me that information related to my health may be disclosed to my family and friends, or as

needed for payment of health care services. I understand that CFCC will only disclose information relevant to my current

treatment. Virginia State law allows parental access to a minor’s health records. I agree that CFCC may disclose health

information to the individuals listed below.

Authorization to (Please Print) _____________________________________ Relationship________________________________________________

Date___/___/_____                             Revoked Date___/___/_____

Authorization to (Please Print) _____________________________________ Relationship________________________________________________

Date___/___/_____ Revoked Date___/___/_____

Patient Name:_____________________________________________________________ Patient Signature:______________________________________

I certify that I have reviewed the following page regarding the Financial Policy of Chester Family Chiropractic Center.

I understand that I may ask questions to CFCC if I do not understand any information contained in the Financial Policy.

I acknowledge full financial responsibility for charges rendered by Chester Family Chiropractic Center as policy states.

Patient (or Guarantor) Signature_________________________________________________________________ Last 4 of SSN:______________

Guarantor’s Relationship to Patient_______________________________________________________________________ Date:________________

Policy Acknowledgements

Chiropractic CenterChester Family

Thank you for choosing Chester Family Chiropractic Center (CFCC) as your trusted provider.

CFCC will be happy to answer any questions regarding this financial policy..

Insurance:

As a courtesy to you, CFCC will verify insurance coverage and prepare estimated costs of services. We will also file claims

associated with participating insurance plans. It is your responsibility to pay any co-pay's, deductibles, co-insurance and/or non-

covered services associated with your specific insurance plan. You are responsible for informing CFCC of changes in insurance

coverage within 30 days from the date of service, or you may be responsible for any charges incurred due to delay in timely

submission of your claims.

Payment at Time of Services:

New and Returning Patient Intake Exam charges are always expected to be paid in full at the time of service. If the insurance

payments and/or the amount of your payment exceed the amount owed for services after insurance processing, the difference will

be refunded back to you or remain as an account credit. You will be required to pay the estimated cost of services at the time of

service unless prior financial arrangements have been made and agreed upon by all parties.

Returning Patients:

Patients returning after an absence in care of six months or more will be required to pay in full any balances for prior care.

Individualized Payment Plans:

CFCC chiropractors recommend treatment plans based on exam findings and patient goals. For those plans, we factor your

insurance benefits, if any, and offer time saving discounts based on prepayment of services. Co-pay's, deductibles, and co-

insurance amounts can not be discounted. Payment plans must be set up on auto debit unless authorized by management.

Declined or Returned Payments:

A $35 charge will be applied to your account for any checks rejected by the bank for any reason. If a pre-arranged credit card

payment plan is established and a payment declines, you may be charged $25 per declined transaction. Please ensure that there are

sufficient funds on the stored credit card to cover these payments prior to setting up payment arrangements and contact our office

immediately with any changes regarding your stored card. Additional fees may be charged by your financial institution.

Delinquent Accounts and Collections

Should this account become delinquent, you agree to pay all collection fees and court costs, including attorney’s fees of 40%.. In

addition, all past due amounts may accrue interest at the rate of 2% per month after 30 days until fully paid.

Financial Policy