• New Patient Paperwork

  •  -

  • Insurance:

  • Date of Incident/Illness*
     - -

  • Has Any Immediate Family Member Ever Been Told They Have:

  • Cancer*
  • Diabetes*
  • High Blood Pressure*
  • Heart Disease*
  • Angina/Chest Pain*
  • Stroke*
  • Arthritis*
  • Osteopenia or Osteoporosis*
  • Depression (Mental Illness)*

  • Do You Currently Experience:

  • Nausea/Vomitting*
  • Fever/Chills/Sweats*
  • Unexplained Weight Change*
  • Fainting Spells/Dizziness/Falls*
  • Headaches/Migraines*
  • Poor Sleep/Fatigue/Mind Fog*
  • Irritability/Fear/Anxiousness*
  • Bowel or Bladder Changes*
  • Cysts (Breast/Ovaries/Other)*
  • Poor / Low Libido*
  • Pregnancy (Possibility of)*
  • Back Pain*
  • Neck Pain*
  • Shoulder Pain*
  • Knee Pain*
  • Arm/Wrist/Hand Pain*
  • Leg/Foot/Ankle Pain*
  • Carpal/Cubital Tunnel*
  • Numbness or Tingling*
  • Neuropathy/Radiculopathy*
  • Do You Drink Alcohol*
  • Do You Smoke*
  • Rotator Cuff Injury*

  • Do You Have Any History Of: (Can be current or past):

  • Surgeries / Medications / Vacinations

  • Upload a File
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  • At Occupational Kinetics we will call to verify your benefits with your insurance company prior to your first visit.  Once you arrive for your first visit we will let you know what was told to us by your insurance company.  At the end of the day we can only repeat what was told to us and it is not a 100% gaurantee of benefits.  The final determination of your benefits will be decided once you claim is submitted and processed by your insurance company. You are ultimately responsible to know your insurance policy.

    We also offer a lab through Norton Health Care System (CPA Labs) that will bill your insurance for tests they can perform. Listed below are tests that are not performed by CPA labs.

    In the event that you don't have insurance or your insurance doesn't cover the service you need we have listed our cash base charges below.

    Specialty Labs, Tests & Service Charges (Not Covered by Insurance)

    Treatment

    Evaluation (Naturopathic, Chiro, OT) - $189.00
    Follow Up Visits (per 15 min) - $30.00 
    Phone Consult (per 15min) - $30.00
    Massage Visits (per 30 min) - $40.00 

    Labs/Tests 

    X-Ray - $50.00
    Saliva Test (Hormone) - $310.00
    Stool Test (Diagnostechs) - $310.00
    Saliva & Stool Test (Diagnostechs) - $410.00
    Hair Analysis (Doctors Data) - $110.00
    Food Allergy Panel (Ig4 Antibodies) - $170.00
    Adrenal Cortisol Stress Panel - $220.00
    Nutrient & Toxic Elements Urine - $150.00
    Fatty Acid Profile - $170.00
    Amino Acid Profile - $185.00
    Organix Profile - $230.00
    Women's Health Profile - $575.00 

  • Thank you for becoming a client at Occupational Kinetics & The Center for Alternative Medicines.  We respect our clients needs to find appointments that your busy lifestyle.  We only ask that you give us 24 hours notice if you need to cancel or reschedule your appointment.  For all evaluations we charge a $90 fee if you NO SHOW or don't cancel your appointment within 24 hours.

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