New Patient

Thank you for choosing Chiro Effect Chiropractic! If you have scheduled a new patient appointment with our office, please fill out the form below in preparation for your visit.  If you have not scheduled an appointment, please do so before filling out the form by calling (269) 327-4813. 

Please complete the form below

Have you called and made an appointment at our office? *
Please call to make an appointment at our office BEFORE filling out this form. Submission of the form is not a guarantee of appointment.
Name *
Address *
Primary Phone *
Primary Phone
Is this a cell phone? *
Secondary Phone
Secondary Phone
Date of Birth *
Date of Birth
Only used for insurance/billing purposes. Providing this number is only through our secure site.
Employed *
Member/Enrollee/Subscriber #
If on the card
Are you the policy holder?
This means it is your name that appears on the card.
Name, Date of Birth, Address and Phone Number if different than Patient
Do you have a secondary insurance?
Insurance Company, Member/Enrollee ID #, and Group Number. (Also, please provide the cardholder's information if other than yourself)
When did symptoms begin? *
When did symptoms begin?
Condition progressively is getting worse? *
Is this related to work or auto accident? *
Are you in litigation for any accidents? *
Are you seeking disability? Or have you been put on disability? *
Date of last chiropractic visit:
Date of last chiropractic visit:
Have you had xrays of the spine taken in the last year? *
Date of last M.D. visit:
Date of last M.D. visit:
On a scale of 0-10 (10 being the most severe) how limited are you in the following areas?
**Without any limitations, we are unable to bill your insurance. Insurance will not cover "wellness" visits.
Do you have any problems with the following?
Check all that apply
Have you had any of the following? If yes, please describe
Wellness History *
Currently, do you:
I certify that I, and/or my dependent(s) have insurance coverage with the company(ies) presented and assign directly to: Chiro Effect Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all changes whether or not paid by insurance. The above named clinic may use my health care information and may disclose such information to the supplied insurance company(ies) and their angents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. Waiting for insurance payment is a courtesy provided by this clinic. We reserve the right to withdraw this courtesy at any time. We will bill your insurance company and accept assignment of benefits during your corrective care period. Direct assignment will be discontinued when you have finished corrective care and a wellness health care program is recommended. We will notify you of the change. If you discontinue your care for any reason including discharge by the doctor; you will be responsbile for any unpaid balance that is not responsibility of the insurance company, regardless of any claims submitted to your insurance company. This clinic does not promise that an insurance company will pay. In the event that the insurance company disputes or rejects the claim, it will be the patient's responsibility to pay the charges and pursue reimbursement from the insurance company. I agree to be financially responsible for all charges incurred at this clinic including my insurance deductible, co-payment and any services rejected by my insurance company. I have read the above provisions and wish to participate in the insurance assignment program. By TYPING my name, I hereby agree to abide by the provisions of this program as specified above.
I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures including x-rays and physiotherapy modalities on me (or ont he practice member named below) for whom I am legally responsible) at Chiro Effect Chiropractic. 1. The purpose of chiropractic care is to contribute to health by the location, analysis, and correction of vertebral subluxations for the restoration of normal nerve functioning. 2. Chiro Effect Chiropractic uses only appropriate techniques selected for my chiropractic care based upon standard professional protocols. 3. Chiropractic adjustments are exceedingly safe when applied properly. I do not expect the doctor to anticipate and explain all of the risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure that the doctor feels at the time, based on the facts known, and is in my best interest. 4. There is a small force introduced into the spine during an adjustment that may laed to temporary minor musculoskeletal discomfort. 5. The doctor will discuss any further risks inherent for my particular case during a report of finding procedure and document this dicussion in my case record. Any questions that I may have will also be addressed at this time. I am an active participant in my chiropractic care, and am therefore invited to ask any questions or express any concerns I have. 5. The doctor will discuss any further risks inherent for my particular case during a report of finding procedure and document this dicussion in my case record. Any questions that I may have will also be addressed at this time. I am an active participant in my chiropractic care, and am therefore invited to ask any questions or express any concerns that I may have. 6. I understand that the doctor or the office receptionist may communicate by telephone call regarding appointments, care information or their details related to my care. 7. I understand that it is my responsibility to inform the doctor should I have a concern regarding the privacy of the area in which I receive care, my patient record or other communications related to my care; and that otherwise, Chiro Effect Chiropractic personnel will make every reasonable effort to ensure my privacy. 8. I have read, or have had read to me, the above consent. By TYPING my name below, I agree to the above-named procedures. I intend this consent form to cover the entire course of care now and in the future. I am free to withdraw my consent and discontinue care at any time.
I acknowledge I am aware of Chiro Effect Chiropractic's "Notice of Privacy Practices" is available to me upon request. I understand I have the right to review these "Notice of Privacy Practices" prior to signing this document. The "Notice of Privacy Practices" describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills or in the performance of health care operations of Chiro Effect Chiropractic. The "Notice of Privacy Practices" is provided on request at the main administration desk of this practice. This "Notice of Privacy Practices" also describes my rights and Chiro Effect Chiropractic's duties with respect to my protected health information. Chiro Effect Chiropractic reserves the right to change the privacy practices that are described in the "Notice f Privacy Practices". I may obtain a revised copy by request which may be delivered by mail or received in the office of Chiro Effect Chiropractic. By TYPING my name, for myself or my dependents, I agree to the above.
As part of our commitment to offer excellent chiropractic and professional care to you and your family, we would like to present our office payment policy in order to minimize misunderstandings about fees. We ask for payment at the time of service. This includes payment for office visits, such as co-payments, deductibles, non-covered services, and services perfomed as a self-pay patient. We require payment at the time of check-out. Our office sends out statements every 30 days, usually occuring between the 13th and 16th of each month. This policy is offered in an attempt to develop and sustain a continued professional and pleasant relationship. Your cooperation is greatly appreciated. There will be a 10% fee added to any balance after 60 days of non-payment. After 90 days of non-payment, you will be sent to collections and an additional 10% fee will be added. Your prompt payment is appreciated. We file all applicable office charges with your insurance carrier(s). However, you are ultimately responsible for all charges. We advise that you familiarize yourself with the benefits of your plan. Prior to any visit, we will assist you in determining your portion of the bill. Please note that insurance is subject to change at any time. This usually includes any un-met deductible, co-payment, and co-insurance which are to be paid at time of service. We accept cash, check, mastercard, visa, american express, or discover. By TYPING my name, for myself or my dependents, I agree to the above.
Cancellations must be made 24 business hours prior to the appointment time to avoid occuring a late fee. Fees are as follows: Same Day Cancellation (Adjustments) - $10 No Call/No Show (Adjustments) - $20 Same Day Cancellation (Massage) - $20 No Call/No Show (Massage) - $40 Multiple rescheduling (after 3 times) will result in a fee: Adjustment - $10, Massage - $20 Attestation Statement: I have read, understand, and agree to the Chiro Effect Payment and Cancellation Policy. I understand that charges not covered by my insurance company, as well as applicable copayments and deductibles, are my responsibility. I acknowledge that these policies do not obligate Chiro Effect to extend credit. I authorize my insurance benefits be paid directly to Chiro Effect. I authorize Chiro Effect to release pertinent medical information to my insurance company when requested, or to facilitate payment of a claim. By TYPING my name below, for myself or my dependents, I agree to the above.