Flow Chiropractic New Patient Intake forms Logo
Language
  • English (US)
  • Spanish (Latin America)
    • Contact Information 
    •  - -
    •  - -

    • Flow Chiropractic is a "non-participating" provider to Medicare patients. This means that if you have Part B you may be entitled to reimbursement for the care you receive in this office. Determination of what can be covered and the amount of reimbursement is specific to your current condition.

      Billing is fairly simple with Medicare and Chiropractic adjustments - Medicare covers the adjustment itself but never any exercises, stretches, or exams (all of which are included in and only applicable to the Initial Visit). The options below describe how you want to handle the non-covered costs of your visit (the price of the exam portion of your first visit).

      Option 1 - The rules are specific that the exam portion is not covered. Choosing this option results in you getting a letter saying just that.

      *Option 2* - This is the best option. This option will not effect your coverage, it will just save paper and postage.

      Option 3 - The exam portion is required to receive care. If you select this option you cannot be seen in this office.

    •  
    • Current State 

    • Headaches

    • Migraines

    • Chief Complaint

      What's the primary reason bringing you in today
    •
    • Health History 
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  
    •  

    • Gynecological History

      Female Reproductive Health
    •  
    •  
    •  
    •  
    •  

    • Male Reproductive Health

    •  
    •  
    • Family History 
    •  
    • Signatures 

    • By signing below you consent to your information being sent to Flow Chiropractic via this secure connection. Flow Chiropractic will not make available any information contained herein unless explicitly authorized by you the undersigned. You submit that all information is accurate to the best of your knowledge.

    • Clear

    • Life isn’t always as organized and simple as we’d like, and we understand that sometimes you’ll need to modify the time or day of your appointment. We also need to build a trust and consistency with care and be respectful of the time set aside for your adjustment. You will receive a reminder the day before your scheduled adjustment. If Flow Chiropractic is not notified of a modification or cancellation at that time, you will be charged at the time of the scheduled appointment. You will then have 1 week to reschedule and receive the adjustment for which you have been charged.

      I agree to have a phone number or email saved in my customer profile for reminders and receipts, as well as a card number on file to execute these policies.

    • Clear

    • Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

      The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. Flow Chiropractic will only use your information internally unless notified and consented to by you, the patient. If you would like to make any changes to your protections guaranteed by HIPAA, please submit requests in writing.

      By signing below you acknowledge your rights to protected health information and agree to disclose such information with Flow Chiropractic.

    • Clear
    • Should be Empty: