Re Exam 2025

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Welcome to our office! Please fill out our Health Record as completely and accurate as possible...
About this Patient
Marital Status
Gender
Reason for this Visit
Is the purpose of this appointment related to:
If job related, have you made a report of your accident to your employer?
Has this condition
Has this condition occurred before?
Does this condition interfere with
Have you seen other doctors for this condition?
Place an X on the image below, where you feel pain, numbness, or tingling:
Mark your Pain Point
Do you exercise regularly?
Do you wear
Health Conditions
FOR WOMEN ONLY
Are you pregnant?
Are you nursing?
Are you taking birth control?
Do you experience painful periods?
Do you have irregular cycles?
Do you have breast implants?

We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously. We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

- Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.

- With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. We would prefer the make up appointment to be within the same week.

Policy Guidelines:

  • Appointments must be cancelled or rescheduled at least 24 hours in advance.

  • Patients who reschedule, cancel late, or do not show up for an appointment will receive a violation notice.

  • After three (3) violations, a $20 fee will be applied for each additional missed, late-cancelled, or rescheduled appointment without proper notice.

- A $50 non-cancellation fee will be administered if you do not show up to your New Patient appointment or call to reschedule before 24 hours of your appointment. Please call or text us if you need to reschedule.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately.
You have the right to receive a "Good Faith Estimate" explaining how much your health care will cost.
Under the law, health care providers need to give patients who don't have certain types of health care coverage, or who are not using certain types of health care coverage, an estimate of their bill for health care items and services before those items or services are provided.
- You have the right to receive a Good Faith Estimate for the total expected cost of any health care items or services upon request or when scheduling such items or services. This includes related costs like medical tests, prescription drugs, equipment, and hospital fees.
- If you schedule a health care item or service at least 3 business days in advance, make sure your health care provider or facility gives you a Good Faith Estimate in writing within 1 business day after scheduling. If you schedule a ...
health care item or service at least 10 business days in advance...
I hereby authorize the Doctor to work with my condition...
My signature below signifies my agreement for payment...
Signature Section
Our Notice of Privacy Practices provides information about...
  • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
  • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
  • The practice may condition receipt of treatment upon execution of this consent.
Signature Section

Thank you for taking the time to fill out this form.

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Please do not submit any Protected Health Information (PHI).

Office Hours

Monday  

9:00 am - 6:00 pm

Tuesday  

9:00 am - 12:00 pm

Wednesday  

9:00 am - 6:00 pm

Thursday  

9:00 am - 6:00 pm

Friday  

9:00 am - 12:00 pm

Saturday  

9:00 am - 11:00 am

Sunday  

Closed