Thank you for requesting an appointment with us! To expedite your check-in process, please complete the following intake form prior to your first visit. This online procedure allows us to reduce your wait times, reduce paper, and treat you faster! It typically takes less than 7 minutes to complete.
If you have any issues completing the online version, we have hard-copy forms in the office so you are more than welcome to complete them when you come in on the first day.
We look forward to seeing you soon!
CHIROPRACTIC PATIENTS: Insurance is not required, but if you will be filing to insurance for your appointments, please provide the following information and send a front/back copy of your insurance cards after completing this form.
*If you are NOT filing to insurance, PLEASE SKIP this section*
Please upload the front and back images of your insurance card if you would like us to look up your benefits in the meantime.
CHIROPRACTIC, ACUPUNCTURE, MASSAGE & COLD LASER THERAPY CONSENT TO TREAT
If a practitioner recommends certain modalities for you, before your treatment, it is important to let them know if you are:
- Are pregnant
- Are being (or have been) treated for cancer
- Have any tattoos, birthmarks, or skin defects/sensitivity on or near the location(s) of your ailments
- Have or have had a pacemaker or other implanted electrical devices or a history of stroke
- Are currently taking light-sensitizing medications (i.e., antibiotics, antidepressants, Retin-A, tetracycline, etc.)
- Are currently taking immunosuppressant drugs (drugs used after organ transplants), steroids,
- Suffer (or have suffered) from seizure disorders
Nature of Chiropractic Treatment
Before beginning treatment, you will be given a physical examination that can include taking vital signs, range of motion testing, muscle strength testing, palpation, orthopedic testing, neurological testing and, if needed X-rays. Once your condition has been diagnosed, the primary method of treatment will be spinal manipulation, also known as spinal adjustment. Adjustments are usually performed by hand but may be performed by hand-guided mechanical instruments. In addition to spinal manipulation, treatment can also involve other forms of therapy including ultrasound, electrical stimulation, traction, hot and cold packs, hydrotherapy, infrared heat, exercise, and nutritional supplements.
Risks of Chiropractic Treatment
All healthcare procedures carry some degree of risk. The most common side effect of spinal manipulation is short-term muscle soreness. More serious side effects can include bone fractures, muscle strain, ligament sprain, joint dislocation, and injury to the arteries, discs, nerves, or spinal cord. Some manipulations of the upper spine have been associated with injury to the arteries in the neck, which could cause or contribute to stroke. However, documented cases are exceedingly rare, and it has been estimated by researchers that the probability of a spinal adjustment causing an injury is one in several million.
PATIENT RESPONSIBILITY FOR CHIROPRACTIC INSURANCE
At Weddington Wellness Center we realize that insurance benefits may be challenging to comprehend. Below are some terms that may help you to understand your insurance benefits.
Deductible
In an insurance policy, the deductible is the total amount of payments that must be made out of pocket by the patient before the insurance company will pay.
Co-Insurance
Co-insurance is the sharing of the costs of a claim between the insurance company and the patient. For example, if the health insurance plan's allowed amount for an office visit is $100.00 and you have met your deductible, your 20% co-insurance payment would be $20.00. The health insurance plan pays the remaining 80% or $80.
Explanation of Benefits (EOB)
An explanation of benefits (commonly referred to as an EOB) is a statement sent by a health insurance company to individuals explaining what medical treatments and/or services were paid on their behalf. The EOB is commonly attached to a check or statement of electronic payment. It also lists the amount of money a patient should pay for the services they have received. If you have questions about your EOB, please ask and we will be happy to help you understand. The most you can pay for covered health expenses in a year through your deductible and co-insurance before your insurance plan will pay 100% of covered medical expenses for the remainder of the plan year.
In Network vs. Out of Network Benefits
If the doctor, hospital, or healthcare facility that you go to is part of your insurance company's network, you'll get your healthcare at lower prices. But if you go to an out-of-network facility, it can become a lot more expensive. Deductibles and co-insurance are a great deal higher when you receive care from an out-of-network provider.
Co-Pay
A copayment or "copay" is a fixed payment for a covered service; this is paid when an individual receives the service. Copayment is defined in an insurance policy and paid by an insured person each time a medical service is rendered. Usually, you can find your copay amount on your insurance card.
I certify that I and/or my dependent(s) either have insurance coverage or am assuming FULL financial responsibility for all charges from Weddington Wellness Center, regardless of if they are paid by insurance. I authorize the use of my signature on all insurance submissions. Weddington Wellness Center may use my healthcare information and may disclose such information to the insurance company(ies) and their agents to obtain payment for services and determine insurance benefits for related services. Please note a 3% surcharge will be added for all credit card purchases.
By checking below, I give my permission and consent to treatment for all services above.