We are so sorry to learn of your incident. Please complete the form below so we can document everything necessary and get you onto the road for recovery! Step 1 of 3 33% 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 First 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*MaleFemaleEmail* Person to contact in case of emergency? (Include name, relationship and best phone number)* Stuff We Need to KnowWhat 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)*Have you ever been under the care of a chiropractor?* Yes No Can't recall Tell us about your previous chirorpactic care... why you went, the outcome and info about your overall experience:*Where you in "good health" and pain free prior to this incident?* Yes No Explain:*Issues I'm dealing with caused by this incident:Speficially describe any and all symptoms and issues you are currently dealing with that are a result of the incident:*Is this a(n)...* Work Injury Auto / Motorcycle Injury Sports Injury Home Injury Recent Fall Bicyle Accident 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 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?Have you ever experienced this or a similar issue prior to this incident? If yes, please explain in detail.*Please describe in great detail everything we need to know regarding the incident:* 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* 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. Payment for services rendered is ultimately YOUR responsibility. That said, we will do everything possible to receive compensation from the appropriate third party payor (insurance company) if applicable based on this incident. Regardless of your coverage, the Doctor will give his/her recommendations and an appropriate care plan for each individual to obtain optimal results. 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 on a single visit. (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 - $250. Chiropractic Adjustments: $30 - $95 Neuromuscular Re-education, Extremity adjustment, Manual Therapy: $55. 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. Also, if the 3rd party payor sends payment for these services directly to me (the practice member), I will sign it over the DREAM Wellness or write a new check for the full amount. If I do not pay DREAM Wellness within 10 days of receiving the payment, DREAM Wellness reserves the right to charge my credit card on file fore the full amount of services rendered plus a 3% credit card processing fee. 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. Have you retained an attorney for this incident?* Yes No, probably not necessary Not yet No, but I would appreciate your help in finding one 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 QuestionaireIn a few sentences or less, and in your own words, describe in detail how your accident happened.*Vehicle You Were InDate of Accident* Vehicle Type* Car Van Wagon Pickup Truck Van Bus Motorcycle Vehicle Size* Sub-compact Compact Mid-size Full-size Mini Light N/A (Motorcycle) What was your position in the vehicle?* Driver Front Passenger Rear Left Passenger Rear Right Passenger Did any parts of your body come in contact with any objects in the car? Windshield, steering wheel, door frame, other? Were you ever unconscious as a result of the accident? If yes, how long?*Where did you go after the accident? Home? Work? Hospital? Other? How did you get there? Did you receive any diagnostic testing or treatment? If so, from whom? Have you seen any other doctor for your injuries? If so, whom? Are you still under a doctor's care? If yes, please explain...*Were there other occupants in the vehicle you were in?* Yes No How many other occupants were in that vehicle and what injuries were sustained if any?*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 Was a police report filed?* Yes No Unsure Do you have a copy of the police report?* Yes No Not yet Unsure If Other Vehicles Were Involved...Skip this section if no 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 None 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
