• New Patient Intake

    Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form. Our office number is 919-322-4383. We look forward to seeing you soon!
  • Please note: We are unable to set up any payment plan arrangement without a valid social security number. If you chose to not provide your social security number, payment will be expected in full at time of service. 

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  • Health Insurance Policy Information

    Please complete this section entirely. ***Please note*** insurance benefits quoted to us are not a guarantee of payment or coverage. We make every effort to verify your benefits, however, you are responsible for any amount shown on your EOB (explanation of benefits) once your claims have been filed. If you are self pay (do not participate with a health insurance plan) please select self pay and move to the next section.

  • The purpose of this section is to let you know about your protections from unexpected medical bills. Gard Wellness Center is out of network with your healthcare insurance or you don't have insurance and you will be subject to our discounted cash rates.

    Gard Wellness Center has partnered with ChiroHealth USA(CHUSA) to address this very problem. CHUSA allows us to discount our fees and still remain compliant with all the new changes to healthcare rules and regulations. To put it simply, healthcare providers offer your insurance a "contractually discounted rate". That same rate cannot legally be available to everyone or we fall out of compliance (not good). 

    CHUSA has no visit limit and no additional co-pay/deductible for the full year of membership. So all that to say what do you owe for your chiropractic treatment?

     

    Enrollment $49

    Initial Exam $75

    Full Spine X-Rays $175

    Adjustment (per treatment) $55

    Re-Evaluation (periodically through treatment) $20

     

    Please initial below to acknowledge this pricing agreement. You will get a full financial estimate at your Report of Findings (next visit). Feel free to call the office with any questions! (919) 322-4383

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  • Current Condition Information

    Please use the following fields to describe what brings you into our office today.
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  • Auto Insurance Information

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  • ***PLEASE NOTE*** If you elect to pursue auto liability insurance to cover the cost of your care, you may not be able to retroactively bill your health insurance due to timely filing guidelines.

    Assignment of Payment
    My attorney and/or insurance carrier are hereby requested and authorized to pay direct to Gard Wellness Center any monies due on account, the same to be deducted from any settlement made on my behalf. Further, I agree to pay Gard Wellness Center the difference, if any between the total amount of charges on my account and the amount paid by the attorney and/or insurance carrier. It is further understood that I, the undersigned agree to pay Gard Wellness Center the full amount of charges on my account should my condition be such that it is not covered by my policy or if for any reason the insurance carrier refuses to pay my claim.

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  • I hereby authorize the aforementioned office and any of its appointed assistants to disclose the following information from the patient's healthcare record.
    This information is to be disclosed to:

    Agency/Business Name: Gard Wellness Center
    Phone #: 919-322-4383
    Fax #: 919-585-5568

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  • Health History

    Please indicate any past or present conditions listed below. Check all that apply.
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  • Fees Update:

    Our comprehensive examination for pregnancy and pediatrics includes use of non-invasive scans including surface electromyography (sEMG) to measure muscle efficiency and tension, heart rate variability (HRV) to measure your stress state/adaptability to stress, and thermography to measure your autonomic nervous system function (the things you can't feel). These tests are FDA approved, but not covered by insurance and will incur a $59 charge. 

    The doctor may decide it is medically necessary to include digital xray imaging of one or more areas of your spine or extremity, regardless of previous imaging. Women who think they may be pregnant will not receive xrays. Please let your doctor know if there is a chance you may be pregnant. Xrays are generally covered by your insurance subject to copay/coinsurance/deductible. Our office performs routine digital xrays yearly to optimize your care and make sure nothing is ever overlooked. These updated images are not covered by insurance and pricing will be discussed at the time of scheduling in the future.

  • Informed Consent:

    As with any healthcare procedure, there are certain complications which may arise during chiropractic manipulation/ massage therapy / acupuncture / cold laser. These complications include but are not limited to: muscle strain, tenderness, fractures, soft tissue injuries, cervical radiculitis and costovertebral strains. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to or contributing to complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. We use comprehensive examinations to screen for contraindications to care; however, if you have a condition that would otherwise not come to our attention, it is your responsibility to inform us.

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