New Patient Intake Form

Personal Information (For chiro, massage, acupuncture, and foot care only)

* Indicates required field

Name *

First

Last

Birthdate *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Email [we send email reminders] *

Occupation *

Employer *

Emergency Contact

Name *

First

Last

Phone Number *

Relationship to you *

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 *

Identification Number *

Policy/Plan Number *

Credit Card Information

Name on Card: *

First

Last

Card Number: *

Expiry *

CVV (3 digits on back of card) *

Health History

Have you had any prior surgeries? *

if yes elaborate *

Have you had any prior hospitalizations? *

Please list any drugs you are taking. *

Please list any vitamins/herbs/homeopathics/other you are taking. *

Do you smoke? *

If yes, how many per day? *

Do you drink alcohol? *

If yes, how many per week? *

Please check current or previous problem/concerns:

Family History

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 Todays 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

Financial and Cancellation Policy

FEE FOR SERVICE
WE ARE A FEE FOR SERVICE FACILITY AND WE REQUIRE PAYMENT AT THE TIME OF YOUR VISIT, APART FROM A LIMITED NUMBER OF COMPANIES FOR WHICH DIRECT BILLING IS AVAILABLE. MANY SERVICES ARE COVERED WHOLLY OR PARTIALLY BY THIRD PARTY INSURANCE; HOWEVER, ULTIMATELY 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.

PRIVATE INSURANCE COVERAGE
YOUR INSURANCE POLICY IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY, NOT BETWEEN YOUR INSURANCE COMPANY AND OUR OFFICE. PLEASE TAKE THE TIME TO VERIFY YOUR COVERAGE FOR CHIROPRACTIC, MASSAGE THERAPY, ORTHOTICS, NATUROPATHY AND/OR TCM, WITH YOUR INSURER BY CONTACTING THEM PRIOR TO YOUR FIRST VISIT. PLEASE INQUIRE ABOUT AND OBTAIN ANY SPECIFIC INSURER MEDICAL PRESCRIPTIONS FOR SERVICE. IF YOU ARE CHOOSING TO SUBMIT RECEIPTS FOR REIMBURSEMENT WE WILL PROVIDE YOU WITH APPROPRIATE PAYMENT RECEIPTS FOR YOUR REIMBURSEMENT EITHER AT EACH VISIT OR AFTER MULTIPLE APPOINTMENTS DEPENDING ON YOUR PREFERENCE.

DVA/RCMP
DIRECT BILLING IS CURRENTLY OFFERED TO DVA/RCMP PATIENTS. IF YOU EXHAUST YOUR COVERAGE PRIOR TO AUTHENTICATION OF AN EXTENSION REQUEST, THEN YOU ARE RESPONSIBLE FOR ANY OF YOUR SERVICES RECEIVED OUTSIDE OF YOUR ORIGINAL COVERAGE. IF FOR ANY REASON DVA OR RCMP WILL NOT APPROVE YOUR CLAIM YOU SHALL ULTIMATELY BE RESPONSIBLE FOR ALL CHARGES

MOTOR VEHICLE ACCIDENT PATIENTS
IN ORDER TO PROVIDE DIRECT BILLING SERVICE UNDER NOVA SCOTIA MOTOR VEHICLE ACT YOU MUST ABIDE BY THE REQUIREMENTS OF THE APPROVED SECTION B PROTOCOLS, WHICH MAY INVOLVE EXHAUSTION OF YOUR PRIVATE INSURANCE COVERAGE (DEPENDING ON INDIVIDUAL CIRCUMSTANCES). IF FOR ANY REASON YOUR MOTOR VEHICLE INSURER WILL NOT ACCEPT YOUR CLAIM YOU SHALL ULTIMATELY BE RESPONSIBLE FOR ALL CHARGES.

WORKER'S COMPENSATION BOARD
IF YOU ARE INJURED ON THE JOB, YOU WILL NEED TO INFORM YOUR EMPLOYER OF THE ACCIDENT AND OBTAIN A WCB CLAIM NUMBER. IF FOR ANY REASON WCB WILL NOT ACCEPT YOUR CLAIM YOU SHALL ULTIMATELY BE RESPONSIBLE FOR ALL CHARGES.

For your convenience, we accept the following forms of payment: Exact Cash, Debit, Visa, MasterCard

Initial Chiropractic Assessment $110
Chiropractic Appointment $65
Chiropractic Appointment &
Acupuncture, Dry Needling, Modalities $75
Re-Examination (New Complaint) $85

30 minute Massage $63.50
45 minute Massage $79.50
60 minute Massage $95
90 minute Massage $160

Initial Naturopathic Assessement $180
Naturopathic Follow-up Appointment $95
Naturopathic Acute Appointment $55
B12 Injection $25
Prolotherapy $30 + visit fee
Neuroprolotherapy $25 + visit fee
IV Infusion Therapy please inquire (depends on type)

Yoga $100

Orthotics $400
Orthotic Footwear $500

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.

Personal Information (**For chiro, massage, acupuncture, and foot care only**)

Emergency Contact

Health Information

Insurance

Credit Card Information

Health History

Family History

Females Only

Reason for Todays Visit

Personal Information (For chiro, massage, acupuncture, and foot care only)