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Chiropractic
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Massage Therapy Treatment Options
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Patient Intake Forms
Chiropractic, Massage & Acupuncture
Naturopathic
>
Adult Intake Form
Meet Our Team
Chiropractors
>
Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
Dr. Maggie McKeough BSc, DC, Medical Acupunture
Massage Therapists
>
Laura Dwyer, RMT
Cassie Hilani, RMT
Adam Blackwood, RMT
Morgan Nearing-Deveaux, RMT
Naturopathic Doctor
>
Dr. Cassandra Connolly, BSc, ND
Acupuncturist
>
Nicole Stallard, RAc, DAc
Reception Staff
FAQs
Contact
Gallery
Videos
Excercises
Personal Information (**For chiro, massage, acupuncture, and foot care only**)
*
Indicates required field
Name
*
First
Last
Birthdate
*
MM/DD/YYYY
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
*
MM/YYYY
CVV (3 digits on back of card)
*
Health History
Have you had any prior surgeries?
*
Yes
No
if yes elaborate
*
Have you had any prior hospitalizations?
*
Yes
No
Please list any drugs you are taking.
*
Please list any vitamins/herbs/homeopathics/other you are taking.
*
Do you smoke?
*
Yes
No
If yes, how many per day?
*
Do you drink alcohol?
*
Yes
No
If yes, how many per week?
*
Please check current or previous problem/concerns:
General Symptoms
*
Headache
Migraine
Sweats
Fainting
Dizziness
Numbness
Tingling
Loss of sleep
Weakness
Loss of strength
Persistent fatigue
Weight loss
High cholesterol
Gastrointestinal
*
Nausea
Gallbladder issues
Diarrhea
Constipation
Vomiting
Belching/gas
Indigestion
Ulcers
Jaundice
Muscles & Joints
*
Swollen joints
TMJ R
TMJ L
Shoulder pain R
Shoulder pain L
Elbow pain R
Elbow pain L
Wrist pain R
Wrist pain L
Hand pain R
Hand pain L
Mid back pain R
Mid back pain L
Low back pain R
Low back pain L
Hip pain R
Hip pain L
Knee pain R
Knee pain L
Ankle pain R
Ankle pain L
Foot pain R
Foot pain L
Swelling of ankles
Fibromyalgia
E.E.N.T
*
Blurred Vision
Double Vision
Earache
Deafness
Ringing in the ears
Asthma
Sinus problems
Frequent colds
Difficulty swallowing
Enlarged lymph glands
Fever
Speech problems
Genitourinary
*
Difficulty urinating
Kidney infection
Bed wetting
Kidney stones
Blood in urine
Frequent urination
Respiratory
*
Chronic cough
Difficulty breathing
Spitting up blood
Chest pain
Tuberculosis
Skin
*
Dry skin
Infectious skin
Disease
Rashes
Easily bruise
Hives
Itchy skin
Eczema/psoriasis
Cardiovascular
*
Bleeding disorder
Heart/blood disease
Stroke
Phlebitis
Varicose veins
Low blood pressure
High blood pressure
Pacemaker
Hemophilia
Heat/cold intolerance
Other
*
Breast lump/pain
Diabetes
Cancer
Seizures
Hepatitis
HIV/AIDS
Family History
Have your grandparents, parents, siblings, or children ever been diagnosed with any of the following:
*
High blood pressure
Hormone problems
Diabetes (Type I/II)
Heart disease
High cholesterol
Mental illness
Depression
Thyroid problems
Kidney disease
Stroke
Osteoarthritis
Cancer
Neurological condition (e.g., MS, Parkinson's)
Rheumatoid arthritis
Breathing/lung problems (e.g., asthma)
I do not know my family medical 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):
*
0
1
2
3
4
5
6
7
8
9
10
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.
Submit
Services
Chiropractic
>
Techniques and Therapies
Custom Orthotics & Footwear
Massage Therapy
>
Massage Therapy Treatment Options
Naturopathic Medicine
>
Vitamin & Nutrient Injections
TCM Acupuncture
Yoga
Mental Performance
Book An Appointment
Patient Intake Forms
Chiropractic, Massage & Acupuncture
Naturopathic
>
Adult Intake Form
Meet Our Team
Chiropractors
>
Dr. Katherine MacAdam, BScKin, DC, MSc, ACC, FCCSS(C).
Dr. Maggie McKeough BSc, DC, Medical Acupunture
Massage Therapists
>
Laura Dwyer, RMT
Cassie Hilani, RMT
Adam Blackwood, RMT
Morgan Nearing-Deveaux, RMT
Naturopathic Doctor
>
Dr. Cassandra Connolly, BSc, ND
Acupuncturist
>
Nicole Stallard, RAc, DAc
Reception Staff
FAQs
Contact
Gallery
Videos
Excercises