Welcome to

Kennesaw, Georgia

At The Wellpath Center we value our patients and aim to provide

not only the best possible chiropractic care, but a smooth

registration process. To make your registration process easier and

less timely, this packet contains helpful information, a map to our

office and several forms which you should fill out prior to your first

visit.

It is important that you read all the forms enclosed in this packet.

Please bring the completed forms to your appointment.

Your driver’s license will be required for proof of identity.

Please arrive 10 minutes prior to your appointment time so that we

may review your completed forms and take care of any other

administrative details. If you have any questions after reviewing

this information please call our office at 770-218-1166.

From Atlanta/Marietta

Take I-75 North to Wade Green Road

Exit 273

Turn left onto Wade Green Road

Stay straight as the road becomes

Cherokee Street

Turn left just after McCollum Parkway

into our parking lot.

The Wellpath Center is in the corner

of the complex.

Suite 401

From Downtown Kennesaw

Follow Cherokee Street out of town

Turn right on McCollum Parkway

The Wellpath Center is immediately

on your right.

Our office is in the corner of the

complex

Suite 401

3590 Cherokee Street, Suite 401, Kennesaw, Georgia 30144

Office Hours

Monday-Friday 10am – 1pm, 3 – 7pm

Saturday 9am – 5pm

Contact Us

3590 Cherokee Street

Suite 401

Kennesaw, Georgia 30144

{ph} 770-218-1166

{fax} 770-218-1006

{email} appointments@wellpath.net

www.wellpath.net

Scheduling Appointments

TWC believes your time is valuable. We see new

patients at special times to minimize your wait to see

the doctor. This is why we ask that you please give us

48 hours notice when cancelling an appointment. This

will give us ample time to restructure our schedule

Payment

Payment is expected at the time of service. Your

insurance coverage and payment plans will be

discussed with the Financial Counselor on your second

visit.

We accept cash, checks and all major credit cards.

TWC also offers Care Credit as a convenient way to

make installment payments without a finance charge.

Terms of Acceptance

When a person seeks chiropractic care and when a chiropractor accepts a practice member

for such care, it is essential that they both are seeking and working toward the same goals.

Chiropractic has one goal. It is therefore important that you understand the goal and the means

to attain it. In this way, there will be NO confusion, misunderstanding, or disappointment.

First, you must realize that Chiropractic is NOT a substitute for medical treatment of any kind, in

any way, for any reason. Also NO statement of the Chiropractor is intended as a medical

diagnosis and should not be confused as such. Practice members usually want to get rid of

whatever ailments, symptoms, or conditions that are bothering them. This, however, is NOT the

goal of the Chiropractor. Chiropractic is not intended to be a treatment of symptoms or medical

conditions.

The purpose of Chiropractic is to restore and maintain the integrity of the spinal cord and its

nerve roots. These vital nerve pathways are housed in and protected by the bones of the spine.

Tiny misalignments of the vertebrae or bones of the spine, which interfere with the function of

these nerve pathways, are called Vertebral Subluxations. Vertebral Subluxations come from

many causes and prevent various organs, glands, and tissues from functioning properly.

By means of a Chiropractic Adjustment, vertebral subluxations are corrected (reduced). Thus,

normal nerve function restores itself. The goal of the chiropractor is to adjust vertebral

subluxations for the purpose of allowing the proper transmission of nerve signals over nerve

pathways so that every part of the body may have proper nerve supply at all times.

This allows the natural healing ability of the body to work at maximum efficiency. With a proper

nerve supply, health improves. In some, symptoms clear up quickly. In others, the process is

slower; and in some, it is only partial or not at all. Regardless of what the disease is called, the

Chiropractor does not offer to heal or even treat it. Nor does she offer advice regarding the

treatment of disease. Her only goal is to allow the body to do its job. Her only means is the

correction of the vertebral subluxation. She promises no cure from and offers no treatment to

disease.

I have read the above, understand it fully, and undertake chiropractic care on this basis.

Patient/Parent or Guardian Signature Date

Patient Health Information

First Name: Middle Name: Last Name:

Sex: Male Female SS#: Date of Birth:

Marital Status: Married Single Divorced Widowed Other

Spouse Name: Number of Children:

Home #: Cell #: Work #:

Email:

Address:

City: State: Zip:

Emergency Contact: Emergency Relation:

Emergency Phone: Emergency Email:

Referral Information:

Referred by: Physician Patient Other:

Advertisement: Yes No Advertisement:

Community Event: Yes No Event Name:

Website: Yes No Website:

Employer Information

Employed: Full time Part Time Homemaker Unemployed Full Time Student Other

Employer:

Employer Address: City: State: Zip:

Occupation: How Many Years:

Work Duties:

Payment Information

Personal Insurance 3rd Party Self Pay Other Do you have an HSA/HRA? Yes No

Responsible Party Name:

Responsible Party Address:

Primary Insured Name: Primary DOB:

Claim #: Claim Contact: Claim Phone #:

Attorney Name: Attorney Phone #:

Personal History:

Last Physical Exam: Primary Phys: Phys Phone #:

Health Conditions:

Previous Chiropractic Care: Yes No Date: Doctor:

Pregnant: Yes No Planning: Yes No Due Date if Pregnant:

Medications:

Supplements:

History of Broken Bones: Yes No If so please list:

Sprains or Strains:

Surgeries:

Auto Accident: Yes No If so, When: Describe:

Struck Unconscious: Yes No If so, How:

History of Stroke: Yes No If so, When:

Family History:

Social History

Alcohol: Daily Weekly Occasion Never Caffeine: Daily Weekly Occasion Never

Diet food Products: Daily Weekly Occasion Never Drugs: Daily Weekly Occasion Never

OTC Stimulants: Daily Weekly Occasion Never Exercise: Daily Weekly Occasion Never

Homemade Food: Daily Weekly Occasion Never Processed Food: Daily Weekly Occasion Never

Soft Drinks: Daily Weekly Occasion Never Tobacco: Daily Weekly Occasion Never

Water: Daily Weekly Occasion Never

Present illness /Conditions:

AIDS Chest Pain Fatigue Low Blood Pressure Sciatica

Alcoholism Cirrhosis/hepatitis Frequent Urination Loss of Smell Scoliosis

Allergies Cold Extremities Hay Fever Loss of Taste Shortness of Breath

Anemia Constipation Headache Memory Loss Sinus trouble

Arteriosclerosis Cramps Heart Problem Menstrual Difficulties Spinal Curvatures/Scoliosis

Arthritis Depression Hemorrhoids Mental/ Emotional Difficulty Spinal Disc Disease

Asthma Diabetes High blood pressure Multiple Sclerosis STD’S

Back Pain Digestive Problems HIV/ARC Nosebleeds Swollen Ankles

Bone fracture Dislocated joints Hot Flashes Pacemaker Swollen Joints

Breast Lump Diverticulitis Insomnia Polio Thyroid trouble

Bronchitis Dizziness Irregular Heart Beat Poor Posture Tuberculosis

Bruise Easily Epilepsy Kidney Trouble Prostate trouble Ulcer

Cancer Eye Problems Loss of Balance Rheumatic fever Varicose Veins

Details of Your Pregnancy

Date of last normal menstrual cycle: Due Date: Number of weeks pregnant:

Names and ages of other

children:

Previous chiropractic care?:

Prenatal History

1. Is this your first pregnancy?

2. How many other births have you had?

3. Have you experienced any traumas during this pregnancy? (accidents, falls) Yes No

If so, please describe.

4. Any medications taken during this pregnancy?

5. Have you had any evaluation procedures? Ultrasound Aminocentesis Chronic villus sampling

6. Please list dates, frequency and reason for these procedures:

7. How has your diet been

during this pregnancy?

8. Have there been any stressful events

in your life during this pregnancy?

9. Do you have any significant fears associated with this birth?

10. Who is your birth

care provider?

11. Will you have someone with you at birth for support

(other than birth care provider)? Yes No If yes, who?

12. Have you put together your birth plan?

Is there anything we should know about you or this pregnancy?

What birthing classes have you decided to take?

Where do you plan to give birth? Do not plan to use an Obstetrician or Midwife?

I would like to receive more information on:

Birth attendants Birth plans Circumcision Infant care Vaccinations

Birthing classes Breast feeding Home birth Ultrasounds

Name of Obstetrician or Midwife:

Practice Name: Phone Number:

Address:

May we have your permission to contact your birth attendant to share information regarding the chiropractic care

that you are receiving here? Yes No

Current Complaint:

What is your chief complaint today?

Injury Occurred: Automobile Work Other Injury Date:

Describe the Discomfort:

How did this occur?

Frequency: Always Hourly Daily Occasionally Other

Interferes with Activities: Yes No Interferes with Sleep: Yes No

Missed Work: Yes No Affected Appetite: Yes No

Reduced Work: Yes No Does it Worsen: Yes No Explain:

What Aggravates the Condition:

What Improves the Condition:

Treatment Received: Yes No Explain:

X-rays Taken: Yes No Dates:

Have you experienced this condition in the past? Yes No If so, When:

Please indicate the current complaints you are experiencing by

marking the areas on the image below.

Consent to Receive Care

I do hereby authorize the doctors of The Wellpath Center to administer such care that is necessary for my

particular case.

I would prefer not to have X-Rays if my condition does not require them and relieve the doctors of The

Wellpath Center of all responsibilities for any complications that might arise from them adjusting me/my I

would prefer to have spinal X-Rays prior to the doctor adjusting me/my child and request a referral to an

imaging center.

Signature: Date:

Financial Policy

The Wellpath Center strives to make the cost of your healthcare affordable. Your

compliance with the financial policies below will eliminate the need for us to send you

a statement and keep administrative costs to a minimum. The following is a summary of

our identification and payment policies.

Identification Requirements

The Wellpath Center is committed to safeguarding your identity. Federal regulations

now require us to verify your identity at each visit and ensure the identity of anyone

presenting medical insurance identification. To satisfy the federal requirements, we ask

for the last four digits of your social security number and a copy of your photo

identification. Furthermore, we will take a digital photograph of you that is attached to

your electronic file. This photograph allows us to verify your identity for future visits.

Refusal to provide the required identification may delay or prevent your being seen by

our providers.

Time of Service Payment

Payment of copays, coinsurance, deductibles, and any outstanding charges is required

at the time services are rendered unless other arrangements have been made in

advance. The Wellpath Center accepts cash, personal check, American Express, VISA /

MasterCard, and Discover. There is a service charge for all returned checks. We do not

accept post-dated checks. Checks are electronically deposited by our office at the

end of each day.

Patients with an outstanding balance of 30 days overdue must make arrangements for

payment prior to scheduling appointments. We recognize some patients have financial

difficulty. Please contact our Practice Manager to make arrangements so you may

receive the care you need.

“I have read and understand the Wellpath Center’s Financial Policy. I agree to the

terms outlined above.”

_____________________________________________

Patient

_____________________________________________

Date

Healthcare Authorization Form I have been provided with a copy of the Notice of Privacy Practices for Protected Health Information. The

Notice of Privacy Practices describes the types of uses and disclosures of my Protected Health Information

(PHI) that will occur in my treatment, payment of my bills or in the performance of health care operations of

this chiropractic office. A copy of our notice is attached and we encourage you to read it and request

your own copy if you would like one.

This Notice of Privacy Practices also describes my rights and duties of the Chiropractor with respect to my

protected health information. I hereby give permission to Whittle Chiropractic Center, Inc. d/b/a: The

Wellpath Center (TWC) to use and/or disclose Protected Health Information in accordance with the

following:

SPECIFIC AUTHORIZATIONS:

I give permission to TWC to use my address, phone number, and clinical records to contact me as

needed.

If TWC contacts me by phone, I give them permission to leave a phone message on my answering

machine or voice mail.

I give permission to TWC to list my first name and last initial on their new patient and referral boards.

I give TWC permission to treat me in an open room where other patients may be present. I am aware

that other persons in the office may overhear conversations between myself and the doctor during the

course of care. Should I prefer to speak with doctor at any time in private, the doctor will provide a

room for those conversations.

By signing this form I am giving TWC permission to use and disclose my protected health information in

accordance with the directives listed above.

The use of this format is intended to make my experience with TWC’s office more efficient and productive,

as well as to enhance my access to quality health care and health information. This authorization will

remain in effect for the duration of my care at The Wellpath Center, plus 7 years or until revoked by me.

You have the right to revoke this AUTHORIZATION, in writing, at any time. However, your written

request to revoke this AUTHORIZATION is not effective to the extent that we have provided services

or taken action in reliance on your authorization.

You may revoke this AUTHORIZATION by mailing or hand delivering a written notice to the Privacy

Official of TWC. The written notice must contain the following information: Your name, Social

Security number, and date of birth; A clear statement of your intent to revoke this AUTHORIZATION;

the date of your request; and your signature. The revocation is not effective until it is received by

the Privacy Official.

I have the right to refuse to sign this AUTHORIZATION. If I refuse to sign this AUTHORIZATION, TWC will not

refuse to provide treatment however, it will not be possible for TWC to file third party billing on my behalf

and I will be responsible for 1) payment in full at the time services are provided to me 2) scheduling my own

appointments since TWC will be unable to contact me 3) all contact with TWC regarding my care.

Additionally, any collection activity as permitted by law is not waived by refusal to sign the authorization.

I have the right to inspect or copy, within boundaries, the protected health information to be

used/disclosed. A reasonable fee for copying will apply. A copy of the signed authorization will be

provided to me.

I have read and understand this Healthcare Authorization Form and acknowledge receipt of the Notice of

Privacy Practices for Protected Health Information. My signature below represents agreement with these

practices.

Social Security Number: XXX-XX-_____________ Date of birth:

Patient Name (please print)

Patient’s signature (or parent/guardian): Date:

Insurance Policy

Providing quality chiropractic and physical therapy care for our patients at an affordable value

is our primary concern. Therefore, to better serve the needs of our patients, we are enrolled in a

variety of managed care plans from numerous insurance carriers.

Each of these managed care plans has different requirements. We make every effort to keep

our records updated on each plan’s individual requirement. However, we must ultimately

depend on you, the insured, to advise us on the requirements for your individual plan so that we

may comply with your plan’s guidelines. Please familiarize yourself with the following information

provided in your policy:

1) Please confirm your plan’s chiropractic benefits, including benefit levels, and any

applicable deductible, copayment or co-insurance.

2) Please check with your insurance company and advise us if your plan requires pre-

authorized visits before a procedure is performed in the office.

If your coverage has changed, lapsed, or expired on the date that services are rendered, all

charges will be denied and become your responsibility. To avoid this, please provide us with your

most current insurance card and keep us advised of any insurance or policy changes as they

occur.

In the event you have a deductible remaining, we will estimate your portion of the charge for

the visit, according to your insurance. You are responsible for this estimated charge. You are

expected to pay your copayments or co-insurance at the time of service. We bill participating

insurance companies for all services performed as a courtesy to you. Charges billed to you are

due at the time we send you a statement. We reserve the right to charge finance charges or

billing fees for accounts not paid in full.

If you have any questions about your financial responsibility, please speak with one of our staff

members, prior to services being performed. By working together, we will help you receive the

benefits you are entitled and provide the quality chiropractic care that you need.

“I have read and understand the Wellpath Center’s Insurance Policy. I agree to the terms

outlined above.”

_________________________________________

Patient

_________________________________________

Date