Patient Name:  Patient->FirstName Patient->LastName 			Date:  System->DateShort
DOB:  Patient->Birthdate	SSN:  Patient->SocialSecurity   	Patient ID:  Patient->PatientID
Address:  Patient->Address    City:  Patient->City    State:  Patient->State	    Zip:  Patient->Zip	
Home Phone: Patient->HomePhone  Cell Phone: Patient->CellPhone  Email  Address:  Patient->Email	
Cell Phone Carrier:		
PLEASE PROVIDE US WITH YOUR CURRENT HEALTH INSURANCE CARD
 AND DRIVERS LICENSE.
IF YOU ARE NOT CURRENTLY INSURED, ASK ABOUT CHIROHEALTH USA ( A $49 A YEAR DISCOUNT PLAN), CARE CREDIT OR OUR IN-HOUSE AUTOPAY PROGRAMS.
Nickname: (preferred to be called)  Patient->Nickname 
Race/Ethnicity: White  ___; African American ___; Native American___; Asian ___; Pacific Islander___
Preferred language: English_____; Spanish_____; Other _____

Have you been diagnosed with:  Asthma/COPD   Diabetes   Hypertension

Person ultimately responsible for this account?	       In the event of an emergency, who should we contact?

Name: __________________________________	       Name: ________________________________________

Relation: ________________________________	       Relationship: ___________________________________

Billing Address: ___________________________	       Cell phone: ____________________________________

SSN: ____________________________________	       Work phone: ___________________________________

Drivers license #:	__________________________	       Home phone: ___________________________________

Work phone: ______________________________	       Who is your Medical Doctor:________________________

       Medical Doctors Phone #: _________________________
I understand that if x-rays are necessary, there is a separate radiology fee of $30 that I must pay to Crosby Chiropractic and Acupuncture Centre at the time of service.

Acknowledgement of receipt of Notice of Privacy Practices:

I hereby consent and state my preference to have my physician, [Physician Name], and other staff at [Practice Name] communicate with me by email or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my health care, which may include, but shall not be limited to, test results, appointments, and billing. I understand that email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my medical care might be intercepted and read by a third party. 

Signature: _____________________________________________________________________

If Legal Representative for the Patient please indicate relationship here:____________________

I authorize Crosby Chiropractic & Acupuncture Centre to release to the following people access to my health record and financial record: __________________________________________________

Assignment of Benefits:

I request that payment of insurance benefits for services provided to me by Jenny L Wiemann, D.C., P.C dba Crosby Chiropractic & Acupuncture Centre, be made directly to the Service Provider as appropriate. I assign any and all rights to payment of insurance benefits to the Service Provider. I acknowledge and agree that I am financially responsible for all charges relating to the services rendered to me or my dependent. If, for any reason, my insurance carrier does not pay for a portion of this bill, I understand that I am responsible for prompt (within 30 days) payment arrangements. , I understand that I am responsible for prompt (within 30 days) payment arrangements. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to this office which accepts assignment.

Signature:___________________________________Date/time:___________________________
Patient, parent or guardian
Patient Name:  Patient->FirstName Patient->LastName 			Date:  System->DateShort

ABN (excluding Medicare):

Jenny L Wiemann, D.C., P.C, dba Crosby Chiropractic & Acupuncture Centre, will file a claim on your behalf with your health insurance carrier(s) based on information that you provided during your registration process. Your carrier may not pay for part of all of the services listed below as they may determine it to be “not medically necessary.” It is important that you understand your coverage as Crosby Chiropractic & Acupuncture Centre will bill you in the event that the service(s) are not covered by your insurance carrier(s) or there is a balance due after payment by your insurance carrier that is determined to be patient responsibility. Services this may apply to include: Out of network chiropractic and acupuncture care,  chiropractic after 26 visits, chiropractic for self-funded or federal plans, chiropractic for maintenance/supportive care, chiropractic for minor children, acupuncture, therapy modalities, xrays, examinations, supplements.

I have read and reviewed these terms with a representative of the provider and I understand that my treatment(s) may not be covered by my health insurance carrier. I agree that I am financially responsible for the amount billed to me by Crosby Chiropractic & Acupuncture and will pay any balance due in a timely manner (less than 45 days). , I understand that I am responsible for prompt (within 30 days) payment arrangements. I authorize the release of any medical or other information necessary to process this claim. I also request payment of government benefits to this office which accepts assignment.

Signature:___________________________________
Patient, parent or guardian

Informed Consent:

I request and consent to any diagnostic testing or treatment from the Doctors/staff of Crosby Chiropractic. I understand that the practice of chiropractic, acupuncture and massage are not exact sciences and I acknowledge that no guarantees have been made to me as a results of medical treatments, diagnostic procedures or examinations that occur within this facility. I further understand that, as in the practice of medicine, there are some risks to treatment including fracture, disc injury, stroke, dislocation and sprains although these are very rare (1 in 4 million). I do not expect the doctor to be able to anticipate and explain all risks and complications and wish to rely on the doctor to exercise those procedures that the doctor feels, at the time are in my best interest.
 
In the event I need  x-rays I authorize them 1) to be taken, and 2) to be sent to Radiology Consultants Midwest, to be read.(initial) __________ and state that to the best of my knowledge I am not pregnant (female only)__________(initial).

Signature: ______________________________________________
Patient, parent or guardian

CONSENT TO TREAT A MINOR
I hereby authorize the doctors at Croby Chiropractic & Acupuncture Centre to administer treatment as they so deem necessary  to my son/daughter  Patient->FirstName Patient->LastName.

Parent/Guardian Signature: ____________________________________

I have read or have had read to me, the above and have had opportunities to ask about the content. By signing below I agree to care for this condition and for any future conditions for which I seek treatment.
Our policy requires payment in full for all services rendered at the time of each visit unless other arrangements have been made. If insurance has not paid within 90 days of the date of service, you will be responsible for the bill. Any legal fees, collection agency, attorney fees, interest fees and any other fees incurred attempting to recoup your account balance are your responsibility.
•	I authorize the staff to perform any necessary services needed during my diagnosis and treatment including x-rays and I understand there is an associated radiology fee of $30, that I am personally responsible for. I also authorize the provider to release any information required to ensure payment of insurance claims.
•	I hereby appoint Jenny L Wiemann, D.C., P.C., including its authorized agents, as my attorney in fact to collect any and all data required to satisfy my financial obligations to this office. I hereby give and grant to my said attorney full power and authority to do and perform all and every act and thing whatsoever to be done.  In order to fully carry out and affectuate the authority granted herein, as fully to all intents and purposes as I might or could do if personally present and personally acting and I hereby ratify and confirm all that my said attorney may do pursuant to this power. 
•	I understand the above information and guarantee that my information, provided electronically and on paper was completed correctly to the best of my knowledge and I know it is my responsibility to inform this office of any changes in the information I have provided

Signature:  __________________________________		Date/time:___________________________
Witness:  ____________________________________		Date:  ______________________________

CROSBY CHIROPRACTIC & ACUPUNCTURE CENTRE	
PATIENT HISTORY FORM	

Date: System->DateShort	
NAME:	Patient->LastName	Patient->FirstName		Birthdate: Patient->Birthdate	
	Last	First	M. I.		
Age:___________ Sex: q F q M				
	
How did you hear about this clinic?		
		
Describe briefly your present symptoms:		

Please list the names of other practitioners you have seen for this problem:		

Orthotics: Y/N                 Mattress age:      Comfortable?                           	Last Spinal Xrays?	
	
Hospitalizations:	

CURRENT MEDICATIONS	
Drug allergies:  q No   q Yes   To what?		
Please list any medications that you are now taking. Include non-prescription medications & vitamins or supplements:	
Name of drug	Dose (include strength & number of pills per day)       How long have you been taking this?	
1.		
2.		
3.		
4.		
5.		
6.		
Living status: alone /not alone		
Smoking status:		
Alcohol use:		
Caffeine use:		
Soda consumption:		
Exercise:		
Patient Name:  Patient->FirstName Patient->LastName 			Date:  System->DateShort
PAST MEDICAL HISTORY	
Do you now or have you ever had:			
			
q Diabetes	q Gout	q Crohn’s disease	
q High/low  blood pressure	q Pneumonia	q Colitis	
q High cholesterol	q Pulmonary embolism	q Anemia	
q Hypothyroidism/hyperthyroidism	q Asthma/bronchitis	q Jaundice	
q Goiter	q Emphysema	q Hepatitis	
q Cancer (type) _________________	q Stroke	q Stomach  or peptic ulcer	
q Leukemia	q Epilepsy (seizures)	q Rheumatic fever	
q Psoriasis	q Celiac/Crohn’s	q Tuberculosis	
q Angina	q Kidney disease/stones	q HIV/AIDS	
q Heart problems/disease/murmur	q Arteriosclerosis	q Chicken Pox	
		
Other medical conditions (please list):		

	

FAMILY HISTORY	

IF LIVING	
IF DECEASED	

Age (s)	
Health & Psychiatric	
Age(s) at death	
Cause	

Father	

	

Mother	

	

Siblings	

	

	

Children	

	

	

Female: q BCP/IUD/                                         Male: q Impotency    q Pain on erection/ejaculation	

              q miscarriages	

	

Patient Name:  Patient->FirstName Patient->LastName 			Date:  System->DateShort
SYSTEMS REVIEW	
	
In the past month, have you had any of the following problems?	
			
GENERAL	NERVOUS SYSTEM	CHIROPRACTIC 	
q Loss/gain of weight	q Headaches	q Headaches	
q Low back pain	q Dizziness	q Excessive worries	
q Fatigue	q Fainting or loss of consciousness	q Difficulty falling asleep	
q Weakness	q Numbness or tingling 	q Difficulty staying asleep	
q Polio/Rheumatic Fever/Scarlet fever	q Memory loss	q Difficulties with sexual arousal	
q Night sweats	q Multiple sclerosis	q Poor appetite	
		q Food cravings	
MUSCLE/JOINTS/BONES	STOMACH AND INTESTINES	q Muscle or Ligament Tears	
q Numbness	q Nausea/vomiting	q Neck Pain/Stiffness	
q Joint pain/numbness	q Heartburn/GERD	q Pain between shoulder blades	
q Muscle weakness	q Stomach pain/abdominal pain	q Pain with coughing/sneezing	
q Joint swelling	q Gas/belching/difficult digestion	q Pain on swallowing	
Where?	q Liver trouble/jaundice	q Poor concentration	
	q Increasing constipation	q Arthritis/Bursitis	
EARS	q Persistent diarrhea/colitis	q Sciatica	
q Ringing in ears/Ear pain	q Blood in stools/black stools	q Jaw pain/TMJ issues	
q Loss of hearing	q Ulcers	q Foot issues	
	q Hemorrhoids	q Hernia	
EYES	SKIN	q Mood swings	
q Pain	q Redness/rash	q Anxiety/Nervousness	
q Redness	q Bruise easily	q Sinus issues
q Depression	
q Loss of vision	q Nodules/bumps/sores	q Irritability/Stress	
q Double or blurred vision	q Hair loss		
q Dryness	q Color changes of hands or feet	OTHER PROBLEMS:	
			
THROAT	BLOOD		
q Frequent sore throats	q Anemia	q get sick easily	
q Hoarseness	q Clots/phlebitis	q loss of smell	
q Difficulty in swallowing	q Poor circulation/Reynauds	q no appetite	
q Pain in jaw	
KIDNEY/URINE/BLADDER		
	q Frequent or painful urination	q gall bladder troubles	
HEART AND LUNGS	q Blood in urine		
q Chest pain	q Bed wetting		
q Palpitations	q Urinary tract infection	Women Only:	
q Shortness of breath	q Nighttime urination	q Abnormal Pap smear	
q Asthma/Bronchitis/wheezing	q PMS	q Irregular periods	
q Swollen legs or feet		q Bleeding between periods	
q Cough (chronic)		q PMS	
		q Excess flow/vaginal discharge	

RADIOLOGY CONSULTANTS MIDWEST

Date:  System->DateShort

Account #:  Patient->PatientID

Patient Name:  Patient->FirstName Patient->LastName 	
Date of Birth:  Patient->Birthdate		SSN:  Patient->SocialSecurity	

Address:  Patient->Address    
City:  Patient->City    State:  Patient->State	    Zip:  Patient->Zip	
Home Phone: Patient->HomePhone  Cell Phone: Patient->CellPhone 

CROSBY CHIROPRACTIC & ACUPUNCTURE CENTRE
Patient Name:	 Patient->FirstName Patient->LastName 		Date: 
OSWESTRY NECK DISABILITY INDEX	
SECTION 1: Pain Intensity
A.  0   I have no pain at the moment.                                          
B.  1   The pain is mild at the moment.                                       
C.  2   The pain comes & goes & is moderate
D.  3   The pain is moderate & does not vary much.                 
E.  4   The pain is severe but comes & goes.                            
F.  5   The pain is severe & does not vary much.                       	SECTION 6: Concentration
A.   0    I can concentrate fully when I want to with no
           difficulty. 
B.   1    I can concentrate fully when I want to with slight
            difficulty. 
C.   2    I have a fair degree of difficulty in concentrating
            when I want to. 
D.   3    I have a lot of difficulty in concentrating when I 
            want to. 
E.   4    I have a great deal of difficulty in concentrating
            when I want to. 
F.    5   I cannot concentrate at all. 	
SECTION 2: Personal Care (Washing, Dressing etc.)
A.  0    I can look after myself without causing extra pain. 
B.  1    I can look after myself normally but it causes extra pain.
C.  2    It is painful to look after myself and I am slow & careful. 
D.  3    I need some help but manage most of my personal
          care.
E.  4    I need help every day in most aspects of self-care.  
F.  5    I do not get dressed; I wash with difficulty and stay in
          bed.	SECTION 7: Work 
A.   0    I can do as much work as I want to. 
B.   1    I can only do my usual work but no more. 
C.   2    I can don most of my usual work but no more.
D.   3    I cannot do my usual work. 
E.   4    I can hardly do any work at all. 
F.   5     I cannot do any work at all.	
SECTION 3: Lifting 
A.   0    I can lift heavy weights without extra pain. 
B.   1    I can lift heavy weights, but it causes extra pain.
C.   2   Pain prevents me from lifing heavy weights off the floor,
           but I can if they are conveniently positioned, for
           example on a table. 
D.   3   Pain prevents me from lifting heavy weights, but I can
          manage light to medium weights if they are conveniently
          positioned.
E.   4   I can only lift very light weights. 
F.   5   I cannot lift or carry anything at all.  	SECTION 8: Driving
A.   0    I can drive my car without neck pain.
B.   1    I can drive my car as long as I want with slight
            pain in my neck.
C.   2    I can drive my car as long as I want with
            moderate pain in my neck.
D.   3    I cannot drive my car as long as I want because
            of moderate pain in my neck. 
E.   4    I can hardly drive my car at all because of severe 
            pain in my neck. 
F.    5    I cannot drive my car at all. 	
SECTION 4: Reading
A.   0    I can read as much as I want to with no pain in my
            neck.
B.   1    I can read as much as I want with slight pain in my
            neck.
C.   2   I can read as much as I want with moderate pain in my
            neck. 
D.   3   I cannot read as much as I want because of moderate 
            pain in my neck.
E.   4   I cannot read as much as I want because of severe
            pain in my neck.
F.   5   I can not read at all because of neck pain. 	SECTION 9: Sleeping 
A.   0    I have no trouble sleeping.
B.   1    My sleep is slightly disturbed (less than 1 hour
            sleepless). 
C.   2   My sleep is mildly disturbed (1-2 hours
            sleepless). 
D.   3   My sleep is moderately disturbed (2-3 hours
            sleepless). 
E.   4   My sleep is greatly disturbed (3-5 hours 
            sleepless). 
F.   5   My sleep is completely disturbed (5-7 hours
           sleepless).	
SECTION 5: Headache 
A.   0    I have no headaches at all. 
B.   1    I have slight headaches that come infrequently. 
C.   2    I have moderate headaches that come in-frequently.
D.   3    I have moderate headaches that come frequently. 
E.   4    I have severe headaches that come frequently. 
F.   5    I have headaches almost all the time. 

Score ______ (50)      Benchmark -5=________	SECTION 10: Recreation 
A.   0    I am able to engage in all recreational activities
            with no pain in my neck at all.
B.   1    A am able to engage in all recreational activities
            with some pain in my neck.
C.   2    I am able to engage in most, but not all,
            recreational activities because of pain in myneck. 
D.   3    I am able to engage in only a few of my usual
            recreational activities because of pain in my neck. 
E.   4    I can hardly do any recreational activiites
            because of pain in my neck.
F.   5    I cannot do any recreational activities at all. 	
Revise Date 4/3/2015

REVISED OSWESTRY BACK PAIN DISABILITY QUESTIONNAIRE

Patient Name:   Patient->FirstName Patient->LastName 		Date:  
This questionnaire will give your provider information about how your back condition affects your everyday life.  Please answer every section by marking the one statement that applies to you.  If two or more statements in one section apply, please mark the ONE statement that most closely describes your problem.

Pain Intensity
•	The pain comes and goes and is very mild.
•	The pain is mild and does not very much.
•	The pain comes and goes and is moderate.
•	The pain is moderate and does not very much.
•	The pain comes and goes and is very severe.
•	The pain is very severe and does not very much.

Personal Care
•	I do not have to change my way of washing or dressing in order to avoid pain.
•	I do not normally change my way of washing or dressing even though it causes some pain.
•	Washing and dressing increases the pain but I manage not to change my way of doing it.
•	Washing and dressing increases the pain and I find it necessary to change my way of doing it.
•	Because of the pain I am unable to do some washing and dressing without help.
•	Because of the pain I am unable to do any washing and dressing without help.

Lifting
•	I can lift heavy weights without extra pain.
•	I can lift heavy weights but it causes extra pain.
•	Pain prevents me from lifting heavy weights off the floor.
•	Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table).
•	Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.
•	I can only lift very light weights, at the most.

Walking
•	Pain does not prevent me from walking any distance.
•	Pain prevents me from walking more than 1 mile.
•	Pain prevents me from walking more than 1/2 mile.
•	Pain prevents me from walking more than 1/4 mile.
•	I can only walk using a stick or crutches.
•	I am in bed most of the time and have to crawl to the toilet.

Sitting
•	I can sit in any chair as long as I like without pain.
•	I can only sit in my favorite chair as long as I like.
•	Pain prevents me from sitting more than 1 hour.
•	Pain prevents me from sitting more than 1/2 hour.
•	Pain prevents me from sitting more than 10 minutes.
•	Pain prevents me from sitting at all.

Standing
•	I can stand as long as I want without pain.
•	I have some pain while standing, but it does not increase with time.
•	I cannot stand for longer than 1 hour without increasing pain.
•	I cannot stand for longer than 1/2 hour without increasing pain.
•	I cannot stand for longer than 10 minutes without increasing pain.
•	Pain prevents me from standing at all.

Sleeping
•	I get no pain in bed.
•	I get pain in bed, but it does not prevent me from sleeping well.
•	Because of pain, my normal night’s sleep is reduced by less than one-quarter.
•	Because of pain, my normal night’s sleep is reduced by less than one-half.
•	Because of pain my normal night’s sleep is reduced by less than three-quarters.
•	Pain prevents me from sleeping at all.

Social Life
•	My social life is normal and gives me no pain.
•	My social life is normal but increases the degree of my pain.
•	Pain has no significant effect on my social life apart from limiting my more energetic interests, eg, dancing, etc.
•	Pain has restricted my social life and I do not go out very often.
•	Pain has restricted my social life to my home.
•	I have hardly any social life because of the pain.

Traveling
•	I get no pain while traveling.
•	I get some pain while traveling but none of my usual forms of travel make it worse.
•	I get extra pain while traveling but it does not cause me to seek alternate forms of travel.
•	I get extra pain while traveling which causes me to seek alternate forms of travel.
•	Pain restricts all forms of travel except that done while lying down.
•	Pain restricts all forms of travel.

Changing degree of pain
•	My pain is rapidly getting better.
•	My pain fluctuates, but overall is definitely getting better.
•	My pain seems to be getting better, but improvement is slow at present.
•	My pain is neither getting better or worse.
•	My pain is gradually worsening.
•	My pain is rapidly worsening.

Back Index Score  ____________

A. Notifier: Crosby Chiropractic & Acupuncture Centre
B. Patient Name: Patient->FirstName Patient->LastName 	  C. Identification Number:
                   Advance Beneficiary Notice of Noncoverage (ABN)
NOTE:  If Medicare doesn’t pay for D. maintenance care below, you may have to pay.Medicare does not pay for everything, even some care that you or your health care provider have good reason to think you need. We expect Medicare may not pay for all the D. maintenance care below. 
D.         	E. Reason Medicare May Not Pay:	F. Estimated       Cost	

98940
98941
98942

	

If determined to be maintenance care
If determined to be maintenance care
If determined to be maintenance care	

30.75
44.26
57.80	
WHAT YOU NEED TO DO NOW: 
•	Read this notice, so you can make an informed decision about your care.  
•	Ask us any questions that you may have after you finish reading.
•	Choose an option below about whether to receive the D.  maintenance care  listed above.
Note:  If you choose Option 1 or 2, we may help you to use any other insurance that you might have, but Medicare cannot require us to do this.
G. Options:     Check only one box.  We cannot choose a box for you.	
☐ OPTION 1.  I want the D. maintenance as listed above.  You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is sent to me on a Medicare Summary Notice (MSN).  I understand that if Medicare doesn’t pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN.  If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles.  
☐ OPTION 2.   I want the   D. maintenance as listed above, but do not bill Medicare. You may ask to be paid now as I am responsible for payment. I cannot appeal if Medicare is not billed.    
☐ OPTION 3. I don’t want the D. maintenance listed above.  I understand with this choice I am not responsible for payment, and I cannot appeal to see if Medicare would pay.	
        H. Additional Information:

This notice gives our opinion, not an official Medicare decision.  If you have other questions on this notice or Medicare billing, call 1-800-MEDICARE (1-800-633-4227/TTY: 1-877-486-2048).  
Signing below means that you have received and understand this notice. You also receive a copy. 
 I. Signature:	J. Date:	
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.  The valid OMB control number for this information collection is 0938-0566.  The time required to complete this information collection is estimated to average 7 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.  If you have comments concerning the accuracy of the time estimate or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850.    
Form CMS-R-131 (03/11)			 			    Form Approved OMB No. 0938-0566

Patient Name:	 Patient->FirstName Patient->LastName 	   UIN: 

Relative Contra-indications

1)	Articular hypermobility and circumstances in which the stability of the joint is uncertain
2)	Severe demineralization of bone
3)	Benign bone tumors of the spine
4)	Bleeding disorders and anticoagulant therapy
5)	Radiculopathy with progressive neurological signs

Absolute Contra-indications

1)	Acute arthropathies characterized by acute inflammation and ligamentous laxity, and anatomic subluxation or dislocation including acute rheumatoid arthritis and ankylosing spondylitis
2)	Acute fractures and disclocations or healed fractures and dislocations with signs of instability
3)	An unstable os odontoideum
4)	Malignancies that involve the vertebral column
5)	Infections of bones or joints of the vertebral column
6)	Signs and symptoms of myelopathy or cauda equine syndrome
7)	For cervical spinal manipulations, vertebrobasilar insufficiency syndrome
8)	A significant major artery aneurysm near the proposed manipulation
Patient has none of these relative or absolute contra-indications

Crosby Chiropractic & Acupuncture Centre
331 Jungermann Rd, St Peters, MO 63376
www.crosbychiropractic.com
(636)928-5588

 Patient->FirstName Patient->LastName 	                                                                                     
CARE PLAN
Patient Name:  Patient->FirstName Patient->LastName           Date:  System->DateShortUIN: ___________
Care Schedule:
9.	Relief:           ____________ a week for ____________weeks = _____________
10.	Correction:       ____________ a week for ____________weeks = _____________
11.	Strengthening:    ____________ a week for ____________weeks = _____________
12.	Supportive:       ____________ a week for ____________weeks = _____________
13.	Supportive       ____________biweekly for ___________weeks =______________
14.	Supportive       ____________monthly for ___________months=______________
Case Re-Evaluation:
1.	6th visit assessment     ______________ weeks/treatment
2.	Re-examination after   ______________ weeks/treatment 
3.	Progress x-ray after     ______________ weeks/treatment
Additional Home Care:
1. Ice Pack	  2. Lumbar Support       3. Neck Pillow            4.   Lumbar seat support
5. Neck Wedge	6. Therabands	         7. Postural exercises	   
*supplements, orthotics, pain patches and biofreeze are not included
Financial Options:
Deductible:_______________________  	Deductible remaining:   _______________________
Co-pay/%: _______________________		Number of visits a year: _______________________
Other Limitations: ___________________________________________________________________
Your Responsibility:__________________________________________________________________

Payment Options:
VIP:  Automatic ach or cc deduction of  $____________ on the __________ of every month towards my balance	
•			Pay $_______________________ each visit (the average cost of finishing active, corrective and supportive care)
•		Pay the co-pay per visit of $______ for active care, $49 for chirohealthUSA membership and $46 a visit when insurance
                  visits are done ($66 with acupuncture)
•		Pay as I go $_____________ a visit 

I understand my  chiropractic care program and that the success of this program is dependent on keeping my appointments, following my doctor’s instructions and communication with my doctor about my case, care and treatment. I also understand that all insurance information listed above was provided by my insurance company that that changes to my financial responsibility may occur. I understand that if I default on my payment I will be responsible for additional fees (legal fees/collection fees/interest and any other expenses).

Doctor signature:_________________________Date: ________________________Patient: __________________________

VIP PAYMENT PLANS

Welcome to our office! We are committed to ensuring that you that you will be receiving the very best care available for your condition and will partner with you to ensure you are able to obtain optimal health for your condition!
_____I authorize the use of my personal credit/debit card to pay for my care.
_____I authorize the use of my bank account to pay for my care.

These Automatic Payments are to be charged on the designated days, weeks or months I have indicated below, on a regular basis until the balance current or outstanding remains at zero.  I understand that this is a binding contract that can only be cancelled through written notification to this office.I also acknowledge that the permission of use for my credit/debit card number will remain private and only accessible for the charges as stated in the above and will be kept in my personal and confidential file.
I agree that each and every provision of this agreement is necessary for the protection of the rights and interests of Crosby Chiropractic Centre and myself.
Designated day, week or month charged: ____________________________
Designated Amount Charged _____________________________________
Card #: _______________________________________________________
Expiration date: ____________________________Sec Code____________
Amount to be charged: __________________________________________
Name: Printed _________________________________________________
Name: Signed ____________________________ Date: ________________
Witnessed: ______________________________  Date: ________________
Your carrier may not pay for part of all of the services listed below as they may determine it to be “not medically necessary.” It is important that you understand your coverage as Crosby Chiropractic & Acupuncture Centre will bill you in the event that the service(s) are not covered by your insurance carrier(s) or there is a balance due after payment by your insurance carrier that is determined to be patient responsibility. Services this may apply to include: Out of network chiropractic and acupuncture care,  chiropractic after 26 visits, chiropractic for self-funded or federal plans, chiropractic for maintenance/supportive care, chiropractic for minor children, acupuncture, therapy modalities, xrays, examinations, supplements.
We try to be sensitive to our patients needs and  are available for short telephone  consultation and writing letters on behalf of our clients to employers, schools, other healthcare providers, attorneys, court services personnel etc. However, phone conversations and clinical work outside of normal appointments that take longer than 15 minutes to complete could be charged at a rate of $30 for every fifteen minute interval. Please note, these charges can not be billed to your insurance company. Ideally clinical work/information should be limited to scheduled appointments

As a courtesy to our doctors and staff, a 24-hour notice is required for all cancelled and rescheduled appointments.  I understand that a $25 late fee may be charged to my account if I do not give the office this prior 24 hour notification

NEW PATIENT INSTRUCTIONS
Thank you for your confidence in our office.  You have placed your health problems in the hands of Crosby Chiropractic and Acupuncture.  Please read and follow these instructions:

•	Explain every change in your symptoms to the Doctor.
•	Plan your schedule so that you will be able to keep your appointments.  This is extremely important in your treatment plan.
•	After your first treatment, you may notice some soreness.  This is to be expected.  We are making changes to your spine and the body needs to adapt to these changes.
•	Do NOT take your neighbors’ and friends’ advice for a “quick cure.”  Their suggestions cost you nothing and usually worth just that.
•	Don’t become discouraged if you see little improvement at the beginning of your treatment.
•	Some patients respond faster than others and your doctor will be honest with you about what you can anticipate.
•	Don’t use home remedies of self medications without informing your doctor.
•	As you begin to feel better, share your joy with friends.  The highest compliment the Doctor can receive is a referral from you.
•	Read the Chiropractic literature you are given.  It will help you understand your recovery process and you will be able to help friends determine whether or not chiropractic care can be advised for them.
•	During your treatment, your doctor may give you some at home therapeutic exercises.  These are an integral part of your treatment program and you should do them as instructed.  Failure to do so can slow down your healing and may jeopardize your ultimate healing.
•	Following your release, it is recommended that you schedule periodic appointments for a spinal check-up.  It is wise to make sure your spine and nervous system are properly aligned.
•	Do bring your children in for spinal check-ups.  Many spinal conditions are hereditary and when detected early, can result in no problems later in life.
•	Resist the urge to “pop” your own spine or allow your friends to “crack your back.”  You are paying for the expertise and knowledge of the doctor.  You deserve no less for yourself.  Let her locate the problem and make the proper corrections.
•	Regardless of your health problems or concerns, consult with your doctor first.  If the problem is not a chiropractic one, they will refer you to the correct health care provider for your concerns.
•	If you have any questions, please do not hesitate to discuss them with your doctor.

 The Doctors and Staff at Crosby Chiropractic & Acupuncture Centre
331 Jungermann Rd, St Peters, MO 63376
(636)928-5588
www.crosbychiropractic.com