Thomas Rogers, D. C.

11701 Hobbiton Trail, Austin, TX 78739
Austin (512) 282-6628 ~ Houston (713) 990-9500 ~ Fax (512) 292-1444
www.ThomasRogersDC.com

Confidential Client History Short Form

Thank you for taking the time to completely fill out this document. It will help create your personal client file and assist Dr. Rogers in individualizing your care. Please print your responses, and also include or email a photo of you for your file. Please attach additional paper should you have extended information regarding any questions.

HEALTH AND LIFESTYLE OVERVIEW

OFFICE POLICIES AND PROCEDURES

We welcome you to our practice and assure you that you will be receiving the very best care available with the goal of resolving/improving your current health status. Please read and initial all of these pages.

The office management strives to facilitate your needs with open communication, and office policies are explained as necessary. We wish to continually improve, self-evaluate, and keep our eyes on the highest good for all.

When You Arrive

Please park on the street or in the driveway so that other vehicles may enter/exit. Please turn off all mobile phones and pagers before entering the building. Please wait only in designated areas. Enter quietly, as a session may be in process. Children must be accompanied by an adult who is not being treated, and need to be taken outside if they are having a noisy day.

Initial Visits

Dr. Rogers personally reviews each new client’s questionnaire BEFORE the appointment time. Initial visits require 60 minutes to clarify history, accomplish exam and non-invasive tests, profiling, report of findings, and tailored recommendations. Depending upon time utilization and constraints, Dr. Rogers will do his best to allow time for treatment if at all possible.

A credit card or electronic checking information will be requested in order to book your appointment, as a financial commitment from you for the time allocated. The payment you submit at booking will be processed on the day of your appointment. (Please read our cancellation policy.) For those unable to come to the office due to distance or illness/disability yet desire assistance for health improvements, please phone our office for consideration of remote consultations.

Payments

All payments are due at the time service is rendered. Initial appointments are paid in advance with a postdated check or submission of credit card information. Please note: Returned checks/stopped payment fee is $35.00. Account balances must be zero in order to schedule the next treatment. 

Hours

Front office hours in Austin are generally 10am – 5:30 pm M-Th, however this can often change depending on Dr. Rogers’ travel schedule. Friday and Saturday, or early or late times may be scheduled by special appointment only, at the after-hours rate. The office works by voicemail if your call cannot be received in that moment. Your call will be returned as soon as possible, and at times that may mean several days if the office is closed, such as when you call near a weekend.

Insurance

Please be aware that our office does not do direct insurance billing. Healthcare services in this office are provided and charged to the client, not your insurance company. Payment is due at the time the services are rendered. Please be aware that chiropractic care offered by Thomas Rogers, DC may not be covered by your insurance plan, however occasionally an MD referral can help.

Upon your request, prior to treatment, we will notate your need for an insurance “superbill” (attending doctor’s statement) that lists medical codes, procedures, and a general diagnosis each time you are treated. Dr. Rogers’ signature is not required on the superbill as the form is authentication in itself. You then attach the superbill to your insurance company’s claim form that you have filled out according to their directions. Your insurance claim is not filled out, or filed, by this office. Next, you mail this to your insurance company. Your personal reimbursement is then determined and paid directly to you by your insurance provider.

We do not have any agreements with any insurance companies, so please be sure you request that any payment be mailed to you. We cannot accept responsibility for negotiating a disputed insurance claim or collecting your insurance claim. If your insurance company requires any additional paperwork including reports, forms, explanations, or itemization of services, a fee of $10 will be assessed to your account for each service date requested.

The client is responsible for full payment whether their insurance reimburses them or not.

Appointment Reminders & Schedule Coordination

It is the client’s responsibility to remember all appointments and to arrive on time. We make friendly confirmation calls as time permits, but the client has the primary responsibility to remember their appointment.

If you are running late for an Austin visit, please call our office to let us know your time frame and to see if the in-person appointment is still available. Remote procedures may offer a solution in this scenario. We know your time is as valuable as our time and we strive to keep on schedule.

Client Referrals

Please help others to help themselves. Passing on the gift of healing allows you to give back just as someone gave the awareness to you that there is help. The healing modalities utilized in this office contain such an effective structure that most likely will help anyone you care to send to us for assistance with their health states, and we sincerely thank you. The practice of Thomas Rogers DC is private and by referral only, however we are selective in who we choose to work with. We work with clients of most all ages. Congratulations for having found your way here, too!

Cancellation Policy

Due to Dr. Rogers’ travel, satellite Houston practice, and symposium events, we respectfully request 48 hours cancellation notice for all Austin appointments, including initial visits. This provides sufficient time to offer that time slot to someone who is waiting to be seen. We reserve the right to charge for the allocated time. Your kind notice allows the office to offer this time to another client. (Please note: we do not double-book like most offices; we reserve the time only for you.)

For the Austin office’s Monday appointments, notice is required by noon the previous Thursday. For Houston clients, cancellation is required by noon on the Friday before the week of your visit.

Without proper notice, the client is charged full fee for the time booked, on the credit card on file, unless another client chooses to utilize the time you had booked.

Nutrition Checks

For nutritional supplementation evaluations, avoid supplement intake on the visit day. Bring anything from home you wish to be tested.

Client Needs & Questions

Your questions and concerns are important to us. Please ask for what you need or do not fully understand. For short questions regarding treatment, write it out clearly and fax it into the office with your return fax number. For longer questions, please schedule a 10 or 15 minute paid consultation. In cases of urgent requests for assistance (flu onset, shock, trauma, changes in symptoms) call for a consult that day if possible. If the office is open and we receive a voicemail from you, we will respond to you as soon as possible. If Dr. Rogers is not in practice that day, you may not receive a response for up to several days. For emergencies, please go to the ER at your nearest hospital or call 911.

Medical Records

To have your medical records released to another healthcare practitioner requires your authorization. A Patient Request for Release of Records form must be completed and signed by you. This form enables Dr. Rogers to release with your permission and to obtain your medical records from another healthcare provider.

Authorization

We request the use of your contact information for the purpose of reminding you about scheduled appointments, re-evaluations, or other appointment-related issues. The use of this information is intended to make your experience with our office more efficient and productive. If you choose not to authorize this information usage, please notify us in writing. Your decision will have no adverse effect on your care from us or on your relationship with the front office.

CLIENT COMMITMENT TO A HEALING PARTNERSHIP

I recognize that Dr. Rogers’ recommendations to assist the body in its healing and self-organization are to reduce nerve and informational interference/confusion and to initiate the process of recovery. I recognize that this recovery is found in greater levels of wellness, regeneration, rejuvenation, and potential longevity by rebuilding, repairing, and renewing the cells of my body.

I choose to unleash my healing potential and jumpstart the process of making my own internal corrections. I elect to update my physiology to better function and attunement with the creative force which guides my healing. I recognize the possibility that the autonomic control system in me can access all information required to restore optimal health by correcting and resolving informational distortions, dysfunctions, subluxations, and underlying factors.

I am willing to commit to whatever time frame is needed and agreed upon (as determined after my initial office visit) to accomplish the changes I seek and want, as long as these fit within my needs and personal considerations. I understand that Dr. Rogers’ intention is to adjust and clear informational faults and subluxations by treating the person and not the disease, and that all responsibility for my healing lies within me.

CLIENT CONSENT TO FOCUS ON HEALING

I happily consent, in all parts and at all levels of who I am, to heal. I consent to make healing a priority and focus, realizing that the more I heal, the more I will succeed in and enjoy all areas of my life. I acknowledge that this consent requires that I increase some happy & positive behavior and decrease other unhappy & negative behaviors.

I consent to minimize complaining & blaming in my life, knowing that they contribute to illness and make it harder to get well.

I consent to maximize praise & gratitude by expressing these toward myself, others, and the Divine.

I consent to minimize worrying about & focusing on negative things, including my health problems, while contributing all I can to changing them.

I consent to rejoice in all improvement in my health and well being.

I consent to notice all fear of getting well in myself, so I can happily and easily release it.

CLIENT AGREEMENT

I have read, understood, and agreed to the Policies & Procedures for this office and I have completed all questions to the best of my knowledge and ability. I agree to commit to a healing partnership and consent to focus on healing.

I hereby permit Thomas Rogers, DC to render chiropractic and energetic wellness care as he deems appropriate and necessary. I understand that Dr. Rogers will not be held responsible for any preexisting medically diagnosed conditions or for any medical diagnosis.

I understand that cancellation without 48 hours notice (or for Houston clients, by the Friday previous to treatment week) will be charged to my credit card.

Credit Card Information

Visa/MC/Amex/D

Permission to Treat Minor – I give Thomas Rogers DC permission to treat the below named minor by signing below, and I agree to be responsible for all charges.

FORGIVENESS

The Rules…of the Game

1. You will receive a body.
You may like it or hate it, but it will be yours for the entire period this time around.

2. You will learn lessons.
You are enrolled in a full-time school called Life. Each day you will have the opportunity to learn lessons. You may like the lessons or think them irrelevant and stupid.

3. There are no mistakes, only lessons.
Growth is a process of trial and error, of experimentation. The “failed experiments” are as much a part of the process as the experiments that ultimately work.

4. A lesson is repeated until learned.
A lesson will be presented to you in various forms until you have learned it. When you have learned it you can go on to the next lesson.

5. Learning lessons does not end.
There is no part of life that does not contain its lessons. If you are alive, there are lessons to be learned.

6. “There” is no better than “here.”
When your “there” has become “here,” you will simply obtain another “there” that will, again, look better than “here.”

7. Others are merely mirrors of you.
You cannot love or hate something about another person unless it reflects to you something you love/hate about yourself. 

8. What you make of your life is up to you.
You have all the tools and resources you need. What you do with them is up to you. The choice is yours.

9. Your answers lie inside you.
All you need to do is listen, look, feel, and trust.

The Signs & Symptoms of Inner Peace

1. A tendency to think and act spontaneously, rather than from fears based on past experiences.

2. An unmistakable ability to enjoy each moment.

3. A loss of interest in judging others.

4. A loss of interest in judging self.

5. A loss of interest in conflict.

6. A loss of interest in interpreting the actions of others.

7. A loss of ability to worry

8. Frequent overwhelming episodes of appreciation.

9. Contented feelings of connectedness with others and with nature.

10. Frequent experiences of smiling through the heart.

11. Increasing susceptibility to love extended by others, as well as the inspiration to extend it.

12. An increasing tendency to let things happen, rather than to manipulate them to make them happen.