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  • 1 - Consent For Care-Adult

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    Eric Malamud
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    This document contains a new patient intake form for Dr. Mario Chavez' chiropractic practice. It collects the patient's contact information, insurance details, and acknowledges financial responsibilities and cancellation policies. Key information includes charges for initial appointments of $150 for x-rays, $50 for exam and $50 for an initial correction, as well as follow up visit costs and a requirement to give 24 hours notice to avoid full charges for cancelled appointments.

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    1_Consent for Care-Adult

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    This document contains a new patient intake form for Dr. Mario Chavez' chiropractic practice. It collects the patient's contact information, insurance details, and acknowledges financial responsibilities and cancellation policies. Key information includes charges for initial appointments of $150 for x-rays, $50 for exam and $50 for an initial correction, as well as follow up visit costs and a requirement to give 24 hours notice to avoid full charges for cancelled appointments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    8 views1 page

    1 - Consent For Care-Adult

    Uploaded by

    Eric Malamud
    This document contains a new patient intake form for Dr. Mario Chavez' chiropractic practice. It collects the patient's contact information, insurance details, and acknowledges financial responsibilities and cancellation policies. Key information includes charges for initial appointments of $150 for x-rays, $50 for exam and $50 for an initial correction, as well as follow up visit costs and a requirement to give 24 hours notice to avoid full charges for cancelled appointments.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
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    of 1

    DR. MARIO CHAVEZ, D.C.

    Date__________
    Last Name____________________________ First_______________________ Middle Int._________ (PN :_________________)
    E-mail Address: ________________________________________________May we send you our monthly email? Yes

    No

    Address: ___________________________________________________City:_________________State:___________Zip:_______
    Home Phone (

    )__________________ Cell Phone (

    )_______________________Work Phone (

    Which number would you prefer to have appointment reminders:

    Home

    Work

    )_____________________

    Cell

    None

    Date of Birth____/____/____ Age_____ Childrens names and age__________________________________________________


    Married: Yes

    No

    Spouse name:__________________________ Referred by:__________________________________

    Occupation______________________________Employer_________________________________________________________
    Are you pregnant? Yes

    No

    N/A

    INSURANCE: We do not take insurance as payment. We will provide you with the insurance form to submit to your
    insurance company for your reimbursement. Please give your insurance card to receptionist to make a copy.
    1st Insurance Co.

    Policy #

    Group #

    Insureds Name

    __________________________________________________________________________________________________________________________________

    2nd Insurance Co.

    Policy #

    Group #

    Insureds Name

    __________________________________________________________________________________________________________________________________

    Insureds Social Security. No. ________________________Medicare: Yes

    No

    No. _____________________________

    Do you understand and accept these charges?


    $150.00 X-rays and Film Analysis (Standard for First Appointment)
    $50.00
    Exam & Report of Findings (Standard for First Appointment)
    $50.00 Office visit with a correction
    $25.00 Re-evaluation (done every 12 visits)
    $20.00 Office visit with no correction
    How will payment be made?

    cash

    check

    credit card

    other _____________

    **Please note that all cancellations must give a 24-hour notice, or full amount of visit will be charged**
    PATIENTS SIGNATURE:
    X
    Signing this gives permission for care

    Date

    VITANOVASPINALCARE,P.C.
    5437SOUTHPRINCESTREET,LITTLETON,CO80120
    PH:303.798.VNSC.www.VitaNovaSpinalCare.com

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