New Patient Intake

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!
Name *

First Name Last Name
Preferred name (if different than legal name)
Patient's Date of Birth *

Month Day Year
Patient's Social Security Number *
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.
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
How did you hear about our office? *

Family Member Friend Doctor Referral Health Insurance Google/Internet Search Facebook/Social Media Ad
Referring Friend/Family Member's Name *
Referring Doctor's Name or Office Name *
Referring Doctor's Office Phone Number *

Area Code Phone Number
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone Number *

Area Code Phone Number
Do you have a Primary Care Physician? *

yes no
Primary Care Doctor's Name or Office Name *
Physician's Phone Number

Area Code Phone Number
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.
Health Insurance Provider *

Aetna Blue Cross Blue Shield (includes Anthem and State Health Plan) Cigna Veteran's Affairs No Insurance/Self Pay
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?

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
Initials *

Clear
Subscriber ID / Member ID *
This is generally listed on the front of your insurance ID card and may be alpha numeric. Please include all characters listed including any listed suffix (01,02,03, etc)
Group Number
Provider Services/Benefits Phone Number (listed on the back of the card) *

Area Code Phone Number
Relationship to the Insured *

I am the policy holder My spouse is the policy holder I am a dependent of the policy holder
Policy Holder's Name *

First Name Last Name
Policy Holder's Date of Birth *

Month Day Year
If possible, please attach a picture of the front of your insurance card

Browse Files

Cancel of
If possible, please attach a picture of the back of your insurance card

Browse Files

Cancel of
Current Condition Information

Please use the following fields to describe what brings you into our office today.
What is your primary reason for coming in? *

I am seeking pain relief and to improve overall function I am not currently experiencing pain, I am seeking services to improve overall health function I am seeking prenatal/postpartum chiropractic care
Please list your health concerns/pain complaints if present (i.e., shoulder pain, migraines, autoimmune disease, etc.) or enter 'Wellness' for if you are looking to improve overall function *
When did your pain complaints begin? *

In the last 28 days 3-6 months ago 7-9 months ago Over a year ago
Do you have a history of any of the following conditions? *

Stroke Heart Attack None of the above
What services are you interested in? *

Chiropractic Adjustments Massage Therapy Acupuncture/Dry Needling Functional Nutrition Laser Therapy Decompression
Is your pain a result of any of the following? *

motor vehicle accident worker's compensation none of the above
Date of Accident *

Month Day Year
Date
Were the police called to the accident? *

Yes, and a police or accident report is available No
Which seat did you occupy in the vehicle at the time of impact? *

front driver side front passenger side rear or back seat
Were you wearing a seatbelt? *

yes no
Did the airbag deploy? *

yes no
Which statement describes the accident best? *

I was completely surprised and did not see it coming I saw it coming
Pleas describe, to the best of your knowledge, what happened during the accident *
Please select the most appropriate statement below regarding your medical treatment after the accident *

I was treated immediately afterwards at an Urgent Care or Emergency Department I was treated within 72 hours at an Urgent Care or Emergency Department, but not immediately after the accident I did not seek medical treatment within 72 hours of the accident
What treatment have you received after Urgent Care or the Emergency Room? *

Chiropractic Care Physical Therapy Primary Care Physician Visit None
What treatment have you received since the accident? *

Chiropractic Care Physical Therapy Primary Care Physician Visit None
Do you have an open claim regarding the accident? *

yes no
Do you intend to open a claim or get an attorney regarding this accident? *

yes no
Auto Insurance Information
Who was the driver of the automobile you were in? *

First Name Last Name
Please select the best option *

I am the responsible party in the accident The other party was the responsible party in the accident Someone else was responsible - if you were not driving but were in the at fault vehicle
Your Auto Insurance Carrier *
Your Auto Insurance Policy Number *
Your Auto Claim Number *
Your Claim Adjuster's Name *

First Name Last Name
Your Claim Adjuster's Phone Number *

Area Code Phone Number
Name of the other vehicle's driver *

First Name Last Name
Other Party's Auto Insurance Carrier *
Other Party's Policy Number *
Other Party's Claim Number *
Other Party's Claim Adjuster's Name *

First Name Last Name
Other Party's Claim Adjuster Phone Number *

Area Code Phone Number
Do you have an attorney handling this claim? *

yes no
Attorney's Name *

First Name Last Name
Attorney's Phone Number *

Area Code Phone Number
***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.
By signing below, you acknowledge your understanding of responsibility of payment. The patient will be responsible for any balance not covered by auto or health insurance.

Clear

The quality of my pain listed above is characterized as *

burning stabbing dull/ache stiff pins and needles / tingling
Does this pain radiate/shoot to any of the following areas (please indicate which side)? *

right left shoulder / arm / hands / fingers buttocks / leg ankle / foot not applicable
Please use the drawing tool to circle your area of complaint(s) From left to right the bodies represent Back, Front and Side positions
This pain is *

constant on and off
Please list all things which make your pain better *

ice heat rest movement / position change sitting standing stretching Rx medication OTC medication
Please list all the things which make your pain worse *

sitting standing movement / position change walking lying down sleeping heat

Please indicate how your condition impacts the following activities of daily living - an answer for each is required. *

	painful	some pain	not affected
bending
lifting
stairs
sitting
standing
walking
exercising
housework
kneeling

Please list any other providers you have seen for this condition

My Primary Care Physician Orthopedic Physician Massage Therapist Physical Therapist Another Chiropractor
Provider/Provider's Office Name *
When did this provider last treat your current condition? (estimate the date to the best of your ability) *
Please list any imaging you have had in the last three months (please bring recent images with you to your first appointment if possible)

Spinal X-Ray Spinal MRI
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
Provider's Name:
Provider's Phone Number

Area Code Phone Number
Provider's Fax Number

Area Code Phone Number
Current Supplements/Over the Counter Medications - list none if you aren't currently taking any *
Prescription Medications - list none if you aren't currently taking any *
Do you use tobacco products?

No Yes Occasionally
How often to you consume alcoholic drinks?

rarely / never 1-3 drinks per week 3-5 drinks per week over 6 drinks per week
Health History

Please indicate any past or present conditions listed below. Check all that apply.
General: *

recent unintentional weight loss fever extreme fatigue none in this category
Musculoskeletal *

Broken Bones Previous Surgery None in this category
Please list any broken bones or surgeries below and their date of occurance: *
Neurological *

numbness or tingling sensations stroke loss of feeling dizziness or lightheaded frequent or recurrent headaches head injury / concussion none in this category
Gastrointestinal *

loss of appetite bloody stool constipation diarrhea nausea or vomitting regular abdominal pain / bloating none in this category
Cardiovascular / heart *

chest pain rapid or heartbeat changes blood pressure regulation problems high cholesterol swelling of ankles and feet history of heart attack diagnosed cardiovascular disease none in this category
Respiratory *

difficulty breathing persistent cough asthma coughing blood none in this category
Eyes / vision *

blurred or double vision eye disease or injury wear glasses / contacts none in this category
Genitourinary *

kidney stones burning / painful urination frequent urination urinary leakage / bed wetting blood in urine none in this category
Endocrine, hematologic, lymphatic *

thyroid problems diabetes cold hands / feet immune system disorder none in this category
Skin and breasts *

rash / itching non-healing sores breast pain breast lump none in this section
Are you pregnant?

yes no it's possible
What is your estimated delivery date?

Month Day Year
Date
Do you have an immediate family history of any of the following? (check all that apply) *

cancer heart disease stroke none of the above
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.
HIPAA Privacy Practices Below
I have reviewed the HIPAA Privacy Practices for Gard Wellness Center (above) - Please sign in the box below: *

Clear
Should be Empty:

New Patient Intake

Health Insurance Policy Information

Current Condition Information

Auto Insurance Information

Health History