Initial Intake Form
The primary system in the body which coordinates health is the CENTRAL NERVE SYSTEM.
Throughout life, stresses and traumatic events can damage the spine and nerve system. These stresses may be PHYSICAL, CHEMICAL, or EMOTIONAL in nature.
The information below will help us to see the types of stresses you have been subjected to and how they may relate to your present spinal, nerve, and health status.
The birth process can traumatize a baby's spine and cause damage to the spine and nerve system. Please indicate where and how you were birthed. (If you don't know, please skip to the next question)
General Physical Trauma
The minor and often ignored repetitive physical traumas that we have endured are often too numerous to list. Please list the major traumas that you remember from your childhood up to the present.
Chemical Stress can occur when a substance, that is toxic to the body, is breathed, injected, taken by mouth, or placed on the skin that is toxic to the body, (e.g.: food allergies, drug reactions, exposure to chemicals in the air, etc.) The following will give us insight into any exposures you may have had.
It is difficult to separate the emotional stress in our life from the physical response that often occurs.
Payment in full is expected on all FIRST VISIT charges. All other fees are to be paid at the time of service unless other arrangements have been made and agreed upon in writing.
First Visit Fee: $85 which includes a consultation, comprehensive chiropractic evaluation, and the report of findings.
Insurance coverage varies greatly. We cannot predict if your policy will cover the services we provide in our office. Please obtain an Insurance Verification Form from our staff and contact your insurance company to determine the amount and extent of coverage. Until this form is complete and returned to us, your account will be on a cash basis.
If your insurance company covers Chiropractic care and you would like us to assist you in the billing process, please fill out the “Insurance Permission” section below.
As a courtesy to you, we will bill your insurance company.
If payment is not received after 30 days, you should contact your insurance company and have them make payment. If, after 60 days, payment is still not received, you will be responsible for payment.
If the insurance company does not reimburse for office visits as you expected that they would, you agree that you are responsible for payment for all uncovered services.
We need your permission with respect to the following two statements or we cannot make claims directly to your insurance company:
“I authorize Cohasset Family Chiropractic to release to my insurance company any medical or other information necessary to process my insurance claims.”
“I authorize payment to be made directly to Cohasset Family Chiropractic. I permit a copy of this authorization to be used in place of the original.”
If you are not the subscriber on your health insurance policy, please provide the following subscriber information which is important for looking up medical benefits information and submitting claims.