New Patient Intake Form

Please complete this form and return it before your first visit
Chiropractic, Massage, Acupuncture Intake Form

* Indicates required field

Name *

First

Last

Birthdate *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email *

Occupation *

Employer *

Emergency Contact

Name *

First

Last

Phone Number *

Relationship to you *

Who can we thank for referring you to us? *

Health Information

Family Doctor *

Phone Number *

Health Card/MSI Number *

Insurance

In order to direct bill your insurance company on your behalf we require a credit card be left on file.

Insurance Company *

Plan Holder's Name *

Policy/Plan Number *

Identification Number *

Credit Card Information
If you do not have a credit card, enter any value into the fields

Name on Card: *

First

Last

Card Number: *

Expiry *

CVV (3 digits on back of card) *

Do you have any allergies? If so, please list and indicate severity *

Please list your medications/vitamins/supplements. *

Health History

Have you had any prior surgeries? *

Have you had any prior hospitalizations? *

If yes to either, please elaborate *

Do you smoke/vape? *

If yes, how many per day? *

Do you drink alcohol? *

If yes, how many per week? *

Past and Present Health Issues

Muscular (muscles, tendons, ligaments) *

Skeletal (bones, joints) *

Nervous (brain, nerves) *

Endocrine (hormones) *

Integumetary (Skin, hair, nails, sweat glands) *

Immune *

Circulatory (heart) *

Urinary & Renal (kidneys, bladder) *

Respiratory (lungs) *

Reproductive *

Digestive *

Other *

Family History

What health conditions occur in your family? (Grandparents, parents, siblings, children) *

Females Only

Are you currently pregnant? *

Yes No

Number of pregnancies *

Number of children *

Are you currently taking any forms of birth control? *

Yes No

Do you experience any of the following? *

Severe menstrual cramps Loss of menstruation Hot flashes Irregular cycles

Reason for Today's Visit

Primary Complaint(s): *

What makes your complaint better? *

What makes your complaint worse? *

When did your complaint begin? *

Rate your complaint (0=no pain, 10=excruciating pain): *

Is your complaint worse in the *

Morning Daytime Evening Night

Is your complaint getting better or getting worse? *

Better Worse Same

Chiropractic
Initial Chiropractic Appointment $150
Chiropractic Appointment $75
Re-Examination $100
Orthotics $500

Acupuncture
Initial Acupuncture Appointment $150
Acupuncture Appointment $100

Massage Therapy
30 minute Appointment $65
45 minute Appointment $85
60 minute Appointment $100
90 minute Appointment $165

Reflexology
60 Minute Appointment $100

Financial Policy
We are a fee for service clinic and we require payment at the time of your visit, apart from companies for which direct billing is available. Many services are covered wholly or partially by third party insurance; however, it is the responsibility of the patient to ensure payment is made at time of service. Our recommendations for care are based upon our desire to see you get and stay well, despite your level of coverage. Insurance plans or coverage maximums are in no way related to your health, but rather are functions of a financial arrangement between you and your insurance provider.

Insurance Coverage

Your insurance policy is a contract between you and your insurance company, not between your insurance company and our clinic. Please verify your coverage with your insurance company by contacting them prior to your first visit. Please inquire about and obtain any specific insurer medical prescriptions for service. We will email you your receipts.

Motor Vehicle Accident

We are a proud MVA NS provider clinic. In order to provide direct billing service under the NS MVA Act, you must abide by the requirements of the approved Section B protocol, which may involve exhaustion of your private insurance coverage. If for any reason, your Insurance company will not accept your claim, you shall be responsible for all charges.

Worker's Compensation

We are a proud WCB NS provider clinic. If you have a workplace injury, you will need to notify your employer of the accident and see your chiropractor for an assessment in order to obtain a WCB claim. If for any reason, WCB will not accept your claim, you shall be responsible for all charges.

Cancellation Policy
We always seek to respect your valuable time by remaining on time and we ask that you respect the time we are holding for you in the same manner.

IF YOU NEED TO CANCEL OR RESCHEDULE YOUR APPOINTMENT, WE REQUIRE 24 HOURS NOTICE, OTHERWISE YOU WILL BE CHARGED FOR THE FULL AMOUNT OF THE APPOINTMENT We hope you understand the hardship our practitioners face in the event of a no show or last-minute cancellation.

When booking an appointment, we require a credit card be left on file to process payments. On the day of your appointment once your insurance has been processed we will run your credit card and email you the receipt to you.

I understand and agree that health/accident insurance policies are between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment any fees for professional services rendered to me will be immediately due and payable.

By clicking submit you are agreeing to the above stated terms and conditions.

ChiropracticMassageAcupuncture

Please complete this form and return it before your first visitChiropractic, Massage, Acupuncture Intake Form

Emergency Contact

Health Information

Insurance

Credit Card Information If you do not have a credit card, enter any value into the fields

Health History

Family History

Females Only

Reason for Today's Visit

Chiropractic
Massage
Acupuncture

Please complete this form and return it before your first visit
Chiropractic, Massage, Acupuncture Intake Form

Credit Card Information
If you do not have a credit card, enter any value into the fields