Entrance form for visitors from another chiropractor: Step 1 of 6 16% Basic Info We Need to Know About YouI am completing this questionnaire for...* Myself Someone other than myself What is your name (the person completing this form)?*What is the relationship to the person you are completing this form for?*I am completing this form for...* My child over the age of 17 My child 16 years old or younger My spouse My friend Do you have an appointment already scheduled at one of our locations?* Yes, in Del Mar Yes, in Pacific Beach No, not yet Great! With whom is your appointment scheduled? (check all that apply)* Dr. Brian Stenzler, Chiropractor Dr. Fatimah Esfahanizadeh, Chiropractor I'm not sure None of the above Great! With whom is your appointment scheduled? (check all that apply)* Dr. Chuck Plante, Chiropractor Dr. Brian Stenzler, Chiropractor Dr. Fatimah Esfahanizadeh, Chiropractor I'm not sure None of the above IF YOU ARE COMPLETING THIS FORM FOR A CHILD 16 YEARS OLD OR YOUNGER, PLEASE CLICK HERE TO SWITCH TO THE CHILD HEALTH HISTORY FORMFirst Name*Middle NameLast Name*Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneMobile Phone*Date of Birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleNumber of ChildrenEmployerOccupationEmail* Preferred Method of ContactMobile PhoneHome PhoneWork PhoneFor appointment reminders, is it ok for us to send text messages to your mobile device?*YesNoWhat company is your mobile provider?*For appointment reminders, what method do you desire?* Email Text Both are fine with me! Who (or what source) may we thank for referring you to DREAM Wellness?*Person to contact in case of emergency? (Include name, relationship and best phone number)* Stuff We Need to KnowReason for Visit*What is your goal for seeking our services?Have you seen your chiropractor for this issue, or is this a new issue since your last visit?* Yes, we have been working on this No, this is a new issue I don't have anything really bothering me; just looking to get "checked" while I'm in town How long have you had this issue?*What do you believe had caused this issue?*Name of your current chiropractor* First Last Phone number of current chiropractor (if available)Appoximate date of last visit / adjustment* Describe any falls, surgery and/or accidents since last adjustment (type none if there are none)*Briefly describe the type of care you receive from your current chiropractor, such as adjustment technique (manual? Drop? Activator? etc.), therapies (roller table? ultrasound? electric muscle stim? etc.), or other helpful information*What Medications Do You Currently Take (if any)?* None Nerve Pills Pain Killers (including Asprin) Muscle Relaxers Blood Pressure Meds Insulin Stimulants Tranquilizers Antidepressants Blood Thinners Sleep Aids Other Please list all other medications your are currently takingPlease list any surgeries you've undergone at any point in your life. Include the reason, approximate date and outcome of the surgery: (Type none if there are none)*Health and Lifestyle HabitsDo you smoke cigarettes* Yes Yes, but I would like to quit Sometimes (that means yes!) No, but I used to No, not ever No, but I live with a smoker Alcohol Consumption* Never Rare (once per week or less) Occasionally (approximately once to three times per week) Frequently (four or more times per week) Daily Exercise Frequency* Never 1-3 times per week 4-7 times per week I'm a "gym rat" Stuff That's Really Good For Us to Know About YouWhat type of wellness providers have you been to in the past? Chiropractor Massage Therapist Acupuncturist MAT Specialist Nutritionist Personal Trainer Life Coach Other Awareness of Your BodyWere you aware that...The central nervous system (CNS) controls all bodily functions and systems?* Yes No Your CNS must be free of interference for optimal health and wellness to exist?* Yes No Goals for My Care...People see wellness providers for a variety of reasons. Some go in the absence of symptoms and to promote wellness throughout a lifetime. Others go for the relief of pain/symptoms. Then there are some who go to correct the cause of their pain/symptoms/challenges. Your provider will weigh your needs and desires when recommending care. Please check the type of care desired so that we may be guided by your wishes whenever possible. (select all that apply)Type of Care Desired (check all that apply):* Wellness Check-up: No symptoms are present and I just want to ensure that my body is functioning optimally. Relief care while away from my regular chiropractor Continue to work on the corrections that my regular Chiropractor is working on Other What type of care do you desire from the doctor(s) at DREAM Wellness?*CURRENT Health Challenges*Please check each of the diseases or conditions that you are currently dealing with. While they may seem unrelated to the purpose of the appointment, they can affect on your care. Headaches Migraines Neck Pain Upper Back Pain Mid Back Pain Lower Back Pain Arm / Elbow / Shoulder / Wrist / Hand Pain Hip Pain Leg / Knee / Ankle / Foot Pain Sinus Issues Dizziness Cancer Loss of Sleep Hepatitis Drug / Alcohol Dependency Digestive Problems Ulcers / Colitis Heart Issues Thyroid Problems Kidney Problems Liver Problems (other than hepatitis) High Blood Pressure Difficulty Breathing (other than asthma) Psychiatric / Mental Health Problems Asthma Arthritis Veneral Disease (other than AIDS/HIV) AIDS / HIV Diabetes (Type II- Adult Onset) Diabetes (Type I) Tuberculosis Shingles Anemia Other None pertain to me When did you start getting headaches? On a scale of 1-10, how bad are the headaches? What helps and what makes the headaches worse? What else should we know about your headaches?*When did you start getting migraines (approximate if you are uncertain)?* What helps and what makes the migraines worse?*How would you describe the pain when you get a migraine? (For example, sharp, dull, crushing, burning, tearing, etc...). Also, is it constant, every now and then, occasionally, rarely?*When you have a migraine, describe as best as you can the location of the pain and whether it stays in that spot or if you feel it radiate (move to) other parts of the body.*Since the very first time you started getting migraines, how has it changed? Is it getting better, worse or still the same. Any information can be helpful.*Describe your neck pain. Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your upper back pain. Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your mid-back pain. Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your low-back pain. Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your shoulder/arm/elbow/wrist or hand pain. Is it right, left or both? Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your hip pain. Is it right, left or both? Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your leg/knee/ankle or foot pain. Is it right, left or both? Include any of the following: How long have you had it? What caused it (if known)? Is it getting better or worse? Is it better or worse now than when it first started? What have you done to make it go away? How does it affect your quality of life? Describe the quality of the pain (constant, occasional, stabbing, shooting, throbbing, local, radiating, etc...) Any other important information.*Describe your sinus issues. Include any of the following: How long have you had them? Are they getting better or worse? Are they better or worse now than when you first started having sinus issues? Any other important information.*How long have you been dealing with dizziness? Is it all of the time or just occasionally? What makes it better and what makes it worse? Can you think of anything that may have brought on your dizziness?*What type of cancer were you diagnosed with? When was it diagnosed? Any information provided would be helpful.*How long have you been having trouble sleeping? Is it all of the time or just occasionally? Any information would be helpful.*When were you diagnosed with hepatits? Is it currently under control? Any additional information would be appreciated.*What types of drugs or alcohol are you dealing with? For how long? Are you working towards getting that under control? Any additional information would be appreciated.*How long have you been dealing with digestive problems? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you been dealing with ulcers/colitis? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you been dealing with heart issues? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you been dealing with thyroid issues? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you been dealing with kidney issues? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you been dealing withl liver issues? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you had high blood pressure? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you had difficutly breathing? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long been dealing with mental health issues? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you had difficutly breathing? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you had asthma? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*How long have you had arthitis? is it osteo-arthritis Rheumatoid arthritis? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*What veneral disease(s) have you been diagnosed with? Please describe the symptoms, what makes them better/worse and what you're currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*When were you diagnosed with AIDS/HIV? Please describe the symptoms and what makes them better/worse. Any additional information would be appreciated.*When were you diagnosed with diabetes? What are you currently doing (if anything) to overcome the problem. Any additional information would be appreciated.*When were you diagnosed with diabetes? How is it currently being controlled? Any additional information would be appreciated.*When were you diagnosed with tuberculosis? How is it currently being treated? Any additional information would be appreciated.*When were you diagnosed with shingles? How is it currently being treated? Any additional information would be appreciated.*When were you diagnosed with anemia? How is it currently being treated? Any additional information would be appreciated.*Of all the health issues you may be dealing with, which is the MOST significant in your life that you would like resolved, whether you think DREAM Wellness can help or not? Also, describe in as much detail as possible, the effect it has on your life. (if there are no health concerns, type "none")*PAST Health History*Please check each of the diseases or conditions that you have dealt with in the past but has gone away or been resolved. While they may seem unrelated to the purpose of the appointment, they can affect on your care. Headaches Sinus Issues Dizziness Cancer Loss of Sleep Hepatitis Drug / Alcohol Dependency Digestive Problems Ulcers / Colitis Heart Attack Heart Issues Stroke Thyroid Problems Kidney Problems Liver Problems High Blood Pressure Difficulty Breathing Psychiatric Problems Asthma Arthritis Veneral Disease AIDS / HIV Diabetes Tuberculosis Shingles Anemia Neck Pain Arm Pain Upper Back Pain Mid Back Pain Lower Back Pain Hip Pain Leg Pain Other None pertain to me Please list any other conditions you are dealing with or had in the pastArbitration AgreementPLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. Simply stated, this agreement says that if a dispute were to arise between you and your provider that we agree to settle it through arbitration as opposed to a jury trial.Arbitration* Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitrate as provided by state and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitrate proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration. Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers or preceptorship interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider, including those working at the health care provider’s clinic or any other clinic or office whether signatories to this form or not. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages. Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrate (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the experiences and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement. The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement. Article 4: General provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribes herein with reasonable diligence. Article 5: Revocation: This agreement may be revoked by written notice delivered to all health care providers within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties. Article 6: Retroactive Effect: By typing your name below, if applicable this will also cover services rendered before the date it was signed, effective as of the date of first professional services. If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By typing my name below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. Type Full Name*By typing my full name above, I acknowledge and agree to the terms above and authorize the DREAM Wellness provider to care for me accordingly.Date* AuthorizationAuthorization for Care*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. I hereby authorize the providers at DREAM Wellness to work with me through the use of procedures and techniques he/she is certified and/or licensed and qualified for, as he/she deems appropriate. I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for all payment. DREAM Wellness will not be held responsible for any pre-existing medically diagnosed conditions or for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered. If I am using insurance benefits to cover the cost of my care (in full or in part), I understand that there is no guarantee that the insurance company will in fact pay my provider the expected amount for my services and the entire fee is ultimately my responsibility (unless prior arrangements have been made in writing). If my insurance coverage or benefits change or are cancelled during my course of care, I acknowledge that it is my responsibility to inform DREAM Wellness of such changes as DREAM Wellness only verifies coverage and benefits at the beginning of care, at the beginning of each new calendar year and when requested by you. Type Full Name*By typing my full name above, I acknowledge and agree to the terms above and authorize the DREAM Wellness provider to care for me accordingly.Date* Issues I may be dealing with right now...As a wellness center, our focus is not on an individual’s problems, complaints and symptoms; rather we specialize in teaching our member’s how to live a proactive wellness lifestyle and provide the tools to do so and overcome challenges when present as naturally as possible. Sometimes it is necessary to learn what may be required to assist in the healing process first, and the information is also important if the member intends on having some of the services reimbursed by an insurance company. Please fill out the form as honestly and accurately as possible. Remember, you don’t need to have a “problem” to benefit from our services. If you are here with no known health challenges at all, you may scroll to the bottom and click "Next" to skip this section.If you scheduled an appointment at DREAM Wellness to overcome a particular challenge, please describe that issue here:Is this a(n)... Work Injury Auto Injury Sports Injury Home Injury Recent Fall Chronic No injury that caused this Overall Frequency of Challenge Constant (100% of the time) Frequent (75% of the time) Intermittent (50% of the time) Occasional (25% or less of the time) Overall Intensity / Severity of the issue? Minimal (An annoyance but has no effect on activity) Slight (Tolerable with some impairment to activity) Moderate (Tolerable with marked impairment of activity) Severe (Intolerable and cannot perform any activities) If this issue is affecting any other area of your body, please explain:If it interferes with your normal daily activities (work, family, recreation, sports), please explain:Does your symptom(s) increase while performing your normal work duties? Yes No Sometimes If yes, how much of the time do you feel your symptoms increase at work?10%20%30%40%50%60%70%80%90%100%What aggravates the issue?What relieves the issue?If this problem went without being taken care of, how do you think if would affect you? Notice of Privacy for: Patient’s Protected Health Information (HIPAA)Notice of Privacy (HIPAA)*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. Notice of Privacy for: Patient’s Protected Health Information (HIPAA) This office abides by the terms described in this policy. This office uses and discloses your protected health care information for the following reasons: To share with other treating health care providers regarding your health care. To submit to insurance companies or Worker’s Compensation Claim to verify that appropriate services have been rendered. To determine patient’s / practice member’s benefits in a health care plan. Releasing information required by State or Federal Public Health law. To assist in overcoming a language barrier when caring for a patient / practice member. Business associates providing written assurances for your privacy have been attained. Emergency situations Abuse, neglect or domestic violence Appointment reminders to household members or answering machines Sign in logs may be disclosed to verify office visits Any other uses or disclosures will only be made with your specific written prior authorization. You have the right to: Revoke authorization, in writing at any time by specifying what you want restricted and to whom. Speak to our privacy officer, who is Brian A. Stenzler, DC., and can be reached at 858-274-2225 regarding privacy issues. Inspect, copy and amend your protected health information and amend it as allowed by law. Obtain an accounting of disclosures of your protected health information. To render a complaint to our privacy officer or the Secretary of Health and Human Services. This office reserves the right to change the terms of this notice and to make new notice provisions for all protected health information that it maintains. Patients / practice members may also get an updated copy upon request at any time by asking the staff. Type Full Name of person receiving care (in agreement with the HIPAA Privacy Notice)*By typing my name here, I acknowledge that I have read and reviewed this notice with full understanding.Type Full Name of Parent, Guardian or Legal Representative (if different from person receiving care)Date* Terms of Acceptance (for Chiropractic & Massage)Terms of Acceptance for Chiropractic & Massage*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. When a practice member receives services at D.R.E.A.M. Wellness®, it is essential for all parties to be working toward the same objective. Chiropractic has only one goal. It is important that each practice member understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our Chiropractic method of correction is by specific adjustments of the spine. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a Chiropractic spinal examination, we encounter non-Chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. Massage is intended to enhance relaxation, reduce pain caused by muscle tension, increase range of motion, improve circulation and offer a positive experience of touch to promote overall body wellness. The general benefits of massage, possible massage contraindications and the care procedures have been explained to me. I understand that massage is not a substitute for medical treatment, and it is recommended that I concurrently work with a Primary Caregiver for any conditions I may have. I am aware that the massage therapist does not diagnose illness or disease, does not prescribe medications and that spinal adjustments are not part of massage. I have informed the massage therapist of all my known physical conditions and medications currently taking and I will keep my massage therapist updated on any changes. Any inappropriate comments, advances or gestures made towards the massage therapists or any provider will not be tolerated and will be asked to leave the premises immediately. Type Full Name of person receiving care (in agreement with the Terms of Acceptance notice)*By typing my name here, I acknowledge that I have read and fully understand the above statements. All questions regarding the caregiver’s objectives pertaining to my care in this office have been answered to my complete satisfaction. I therefore accept Chiropractic care and/or massage on this basis. Chiropractic Informed ConsentInformed Consent to Receive Chiropractic Care*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. Chiropractic Informed Consent to Receive Care I hereby request and consent to the performance of chiropractic procedures, including the potential use of diagnostic x-rays and any supportive therapies on me (or on the member named below, for whom I am legally responsible) by the doctor of chiropractic indicated named below, including those working at the clinic or office listed below or any other office or clinic below and /or other licensed doctors of chiropractic and support staff who now or in the future care for me while employed by, working or associated with or serving as back-up for the doctor of chiropractic, whether signatories to this form or not. I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office personnel the nature and purpose of chiropractic adjustments and procedures. I understand and I am informed that, as is with all Healthcare services, in the practice of chiropractic there are some inherent risks to care, including, but not limited to, muscle spasms for short periods of time, aggravating and/or temporary increase in symptoms, lack in improvement of symptoms, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, and is in my best interests. Fractures are rare occurrences and generally result from some underlying weakness of the bone which our doctors check for during the taking of your history and during examination and X-ray. Stroke has been the subject of tremendous disagreement. The incidences of stroke following a chiropractic adjustment are exceedingly rare and are estimated to be associated with the procedure between one in one million and one in five million cervical “manipulations”. The other complications are also generally described as rare. I further understand that Chiropractic adjustments and supportive care is designed to reduce and/or correct subluxations allowing the body to return to improved health. It can also alleviate certain symptoms when present through a conservative approach with hopes to avoid more invasive procedures. However, like all other health modalities, results are not guaranteed and there is no promise to cure. Accordingly, I understand that all payments(s) for care are final and no refunds will be issued. However, prorated fees for unused, prepaid services will be refunded if you wish to discontinue care. I further understand that there may be options available to treat my condition and/or symptoms (if present) other than chiropractic procedures. These treatment options may include, but not limited self-administered, over the counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; physical therapy; steroid injections; bracing; and surgery. I understand and have been informed that I have the right to a second opinion and secure other opinions if I have concerns as to the nature of my symptoms and treatment options. I have read, or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent to cover the entire course of care for my present condition and for any future condition(s) for which I seek care. Type Full Name of person receiving care (in agreement with the Informed Consent Notice)*By typing my name here, I acknowledge that I have read and fully understand the above statements regarding informed consent. Type Full Name of Parent, Guardian or Legal Representative (if different from person receiving care)Date* 24 Hour Cancellation Policy24 Hour Minimum Appointment Change/Cancellation Policy*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. This section is to advise you of our office’s 24 hour cancellation policy. Due to the overwhelming demand and limited appointment slots, we are unable to hold an appointment time for you if you are not able to keep it. Giving us notice of 24 hours or more allows us to fill the appointment time slot from the waiting list of others needing an appointment. If you need to cancel your scheduled appointment, please notify us as soon as possible, at the very latest 24 hours prior to your scheduled appointment. If you cancel an appointment with fewer than 24 hours notice, or fail to show up for your scheduled appointment, you will be charged a cancellation fee up to the amount of your scheduled service(s). (If you are scheduled for a service from a package previously purchased, you will lose that visit.) Type Full Name Here (in agreement with the 24 hour cancellation / appointment change policy)*By typing your name, you acknowledge the above and fully understand the cancellation policy and permit us to charge your credit card on file if necessary to cover the cancellation fee.Fee Schedule and Financial Policy for Chiropractic & MassageOur experience has shown that it is wise to have an understanding with our practice members as to our office policies and fees. Therefore, this information has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and we will do our best to help you. Fee Schedule*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. Important: All practice members are responsible for full payment for the first visit (unless other arrangements have been made in advance.) Insurance: We will verify all insurances and your benefits per your agreement with your carrier. Regardless of your coverage, the Doctor will give his/her recommendations and an appropriate care plan for each individual to obtain optimal results. Payment for services rendered is ultimately YOUR responsibility. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. Many of our practice members receive our services as part of a package, hence the reason for the variation in prices. Also, fees may vary based on whether they are being paid on a cash or insurance basis. (All practice members, whether they have insurance or not, have the opportunity to receive our cash prices and may choose not to utilize their insurance coverage.) As part of our routine care, multiple services may be performed at a single time. (When using insurance, it is common to see some of these services listed on your explanation of benefits you will receive from your carrier. If you are unclear about what service you will be personally responsible to pay, please ask the office coordinator or provider prior to receiving the service.) Consultation: No Charge Initial Chiropractic Exam: $50-$250 Chiropractic re-examination: $60-$90 *X-Rays (May be included in exam fee- inquire within): $50 - $175 Chiropractic Adjustments: $25 - $75 Neuromuscular Re-education, Extremity adjustment, Manual Therapy: $45 30 Minute Massage: $40 - $80 60 Minute Massage: $49 - $110 If you would like a full description of each service listed above, please ask your provider. Agreement: By typing my name below signifies my agreement for payment in full on a cash basis if I have not provided DREAM Wellness with all necessary insurance documents and information by the time of the second visit. Who should receive bills due for services rendered (partial or total)? Check all that apply* Self Spouse Health Insurance / Auto Insurance Parent / Guardian Workman's Compensation Other Important: All practice members are responsible for full payment for the first visit (unless other arrangements have been made in advance.) Type Full Name (in agreement with financial policy)**It is understood and agreed that the payments to DREAM Wellness for X-Rays is for examination of X-rays only. The X-ray negatives will remain the property of this office. They are kept on file where they may be seen at any time. If you desire a copy of your films, they will provided to you at the cost incurred to DREAM Wellness. Insurance PoliciesInsurance Policy*PLEASE CLICK THE BOX ONCE YOU HAVE READ AND AGREE TO THE STATEMENT. (This pertains to everyone even if not planning on using insurance at this time.) DREAM Wellness is a not an insurance-dependent wellness center, but rather one that is focused on assisting its members bridge the gap from a reactive system of “sick care” to a proactive model of wellness care. That being said, some people utilize our services strictly for the relief of symptoms, some to correct a problem, and others (with no symptoms at all) choose to utilize our services because they understand the benefits of a wellness lifestyle. While insurance may cover some of the services offered at DREAM Wellness, they typically cover them based on what they consider to be clinically necessary. Some insurance plans cover wellness (maintenance) care (with or w/out symptoms), some cover corrective care (with or w/out symptoms) and some only cover symptomatic relief care. As a service to our members, we will gladly verify your insurance benefits with your carrier and do our best to see if they will cover any of the services you may receive at our center. However, when we verify, they clearly explain that whatever they tell us is not a guarantee of payment. Therefore, as a health care provider and a business, we, too, must protect ourselves to ensure that we receive payment for services rendered. When you accept care in our office, we may offer the service of filing your insurance for you. Ultimately, however, YOU are responsible for all charges on your account. Should we file insurance claims on your behalf, we will do the best we can do to maximize your insurance benefits while maintaining honesty & integrity in the 3rd party reimbursement system. By typing your name below, YOU are agreeing on our terms on non-assignment of benefits statement. Non-Assignment of Benefits: As a courtesy, the doctors may submit the insurance claims to my carrier and not charge me the full cost of the services up front. If DREAM Wellness is NOT an in-network (participating) provider with my insurance carrier, insurance payments for the services I received at DREAM Wellness may be sent directly to me. If so, I agree to sign over and present all insurance checks I receive to DREAM Wellness within five (5) business days of receipt. I also have the option of writing a personal check for the total amount of insurance reimbursements I receive and presenting that to DREAM Wellness within five (5) business days as an alternative. If on a pre-pay plan, DREAM Wellness will refund me any money that may be owed to me based on the plan agreement within five (5) business days. I will provide my valid credit card number and expiration date in the event that I do not turn over any and all insurance checks that I receive that are due to DREAM Wellness, and my card will be charged accordingly for those amounts. If so, I also agree that I will be charged an additional 3% of the balance to pay for credit card service fees and other administrative costs that would not have otherwise been incurred had I brought the checks in at the time of receipt. I have read and understand the terms of the Insurance Policies and Non-Assignment of benefits. I hereby authorize DREAM Wellness to release any information to any third party payor regarding my care for the purpose of processing my claim. I authorize and request my insurance company to pay directly to DREAM Wellness any amounts that would otherwise be payable to me for the services I received. I also authorize payment to be taken directly from my credit card in the event that I do not fulfill this agreement and obligation to DREAM Wellness. Type Full Name (in agreement with insurance policy)*Date* Auto Accident QuestionaireVehicle You Were InDate of Accident* Vehicle Type* Car Van Wagon Pickup Truck Van Bus Vehicle Size* Sub-compact Compact Mid-size Full-size Mini Light What was your position in the vehicle?* Driver Front Passenger Rear Left Passenger Rear Right Passenger A) At the time of the accident, what was your vehicle doing?Was your vehicle stopped for... Traffic Light Pedestrian Intersection Parked Stop Sign Traffic Was your vehicle slowing down for... Traffic Light Pedestrian Intersection Parking Stop Sign Traffic Turning Was your vehicle moving... Slowly Moderately Fast Accelerating Approximately what speed were you going at the time of impact?What extent of damage did the vehicle you were in sustain?* Minumal Moderate Extensive Totaled Unsure B) If Other Vehicles Were Involved...Type of Vehicle that Struck Your Vehicle Car Van Wagon Pickup Truck Van Bus Size of First Vehicle to Strike Your Vehicle Sub-compact Compact Mid-size Full-size Mini Light How did this vehicle strike the vehicle you were in? Head on Rear ended From right From left What extent of damage did this vehicle you were in sustain? Minumal Moderate Extensive Totaled Unsure Were any other vehicles involved in this collission? Yes No Unsure Please tell us about all other vehicles involved in this collission...Conditions at the time of AccidentWhat time of day did the accident occur?* Dawn Daylight Sunset Dusk Night What was the condition of the road at the time of the accident?* Dry Wet Damp Snow covered Icy If visibility was hindered at the time of accident, was it because of... (leave blank if not hindered) Sunlight Fog Darkness Rain Snow Traffic Were any traffic citations issued as a result of the accident?* No citations issued Driver of other vehicle Driver of the vehicle you were in You Unsure At the moment of impact...Were you prepared for the collision* Accident was a complete surprise Aware of impending collision And braced for collision Was your foot on the brake pedal at the time of collison?* Yes No Unsure Was your foot knocked off the brake pedal?* Yes No Unsure Were you wearing a seatbelt?* Yes No What type of seatbelt?* Shoulder-lap Shoulder only Lap only What position was the headrest at the time of the collision? Low Middle High Unsure Was your head touching the headrest at the time of impact* Yes No Unsure Was the vehicle you were in equipped with airbags?* Yes No Unsure Did the airbags deploy?* Yes No What position was your BODY at the time of impact* Straight Leaning forward Turned to the right Turned to the left Unsure What position was your BODY thrown as a result of the collision?* Forward / Backward Backward / Forward Sideways Across the vehicle Outside the vehicle Under the vehicle Unsure What position was your HEAD & NECK at the time of impact* Straight Tilted forward Turned to the right Turned to the left Unsure What position was your HEAD & NECK thrown as a result of the collision?* Forward / Backward Backward / Forward Sideways Don't recall Did not move Type Full Name*By typing my name here, I am confirming that I have expressed the complete truth regarding this accident to the best of my knowledge, memory and ability.Date* Δ
