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  • English (US)

  • APPLICATION FOR CARE

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    Pick a Date
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    Pick a Date

  • Employer:      Occupation:      

  • Spouse's Name         
    Spouse's Employer          
    Name of Emergency Contact:   *   *
    Contact Number:      *
    Relationship:      

  • HISTORY OF COMPLAINT

  • Is your problem the result of ANY type of accident?       If so, what?      
     
    Chief Complaint      
    How Long have you had this?      
    First Time Ever?      
    How Often (past 14 days)      

    Looking at Past:
    Accidents/sports injuries/traumas      
    Typical day at work      

    What have you tried for your chief complaint?
    Doctors / PT / Massage / Therapists      
    Chiropractor:         How Long Ago?      
    For same concern?            Freq?      X-rays         
    Medications      
    Home Remedies      Over the Counter      

    And nothing has CORRECTED this, is that right?       
    Describe pain at absolute worse?     Pain 1-10?      
    Does it radiate?      
    Specific Goals (home/hobbies/work)       

  • PLEASE MARK the areas on the body diagram with the following letters to describe your symptoms

    R= Radiating B=Burning D=Dull A=Aching N=Numbness S=Sharp/Stabbing T=Tingling

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  • Surgeries( What type, and When?)      
    Pregnant (Due Date)   Pick a Date   
    Occupation           

  • Family History
    Does anyone in your family suffer with the same condition(s)            If yes, whom?              
    Have they ever been treated for their condition?           
    Any other hereditary conditions the doctor should be aware of?          What?         

  • Social History
    Smoking:      *     How Often?     
    Alcoholic Beverage: Consumption Occurs               If Yes. how often?         
    Recreational Drug Use:      *       If Yes. how often?                 

  • Informed Consent

    I have been advised that chiropractic care, like all forms of health care, holds certain risks. While the risks are most often very minimal, complications such as sprain/strain injuries, irritation of a disc condition, and although rare, minor fractures, and possible stroke-which occurs at a rate between one instance per one million to one per two million, have been associated with chiropractic adjustments. 


    Treatment objectives, as well as the risks associated with chiropractic adjustments and all other procedures provided at Covington Family Chiropractic LLC have been explained to me to my satisfaction and I have conveyed my understanding of both to the doctor. After careful consideration, I do hereby consent to treatment by any means, method, and or techniques, the doctor deems necessary to treat my condition at any time throughout the entire clinical course of my care.

    I hereby authorize payment to be made directly to Covington Family Chiropractic LLC, for all benefits which may be payable under a healthcare plan or from any other collateral resources. I authorize utilization of this application, or copies thereof, for the purpose of processing claims and effecting payments, and further acknowledge that this assignment of benefits does not in any way relieve me of payment liability and that I will remain financially responsible to Covington Family Chiropractic LLC for any and all services I receive at this office.

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  • X-Rays/Imaging Studies*

    By my signature below, I am acknowledging that the doctor and or a member of the staff has discussed with me the hazardous effects of ionization to an unborn child, and I have conveyed my understanding of the risks associated with exposure to x-rays. After careful consideration, I therefore do hereby consent to have the diagnostic X-ray examination the doctor has deemed necessary in my case.

  • FEMALES ONLY: Please read carefully, check the boxes, include the appropriate date, then sign below if you understand and have no further questions, otherwise see our front desk staff for further explanation

                 Pick a Date   
          

  • Medical Information Release* - (HIPAA Release)

    I hereby authorize Covington Family Chiropractic LLC to furnish information to insurance carrier(s) concerning my diagnosis and treatment. I authorize Covington Family Chiropractic LLC and affiliated business associates to contact me regarding appointments and billing inquiries. I acknowledge that I was offered a copy of the Notice of Privacy Practices policy issued by Covington Family Chiropractic LLC on the date indicated below. I also specifically authorize Covington Family Chiropractic to discuss my personal health information with the following people:

  • Financial Policy Agreement*

    1. Each patient is responsible for his/her own care plan. As a courtesy, we will file for UHC and Medicare. It is your responsibility to make sure that you provide all current insurance information to our office. However, you will be responsible for any outstanding balances, whether or not your insurance company pays.
    2. Bills unpaid for more than 60 days will be turned over to a third party and/or collection agency. Additional fees may be incurred in the collection of any outstanding balances.

    3. We may charge up to $25 for the reproduction of your medical records based on guidelines from the State of Georgia and the federal government.

    4. A $30 fee will be charged on all returned checks.

    5. A $20 missed appointment fee will be charged for any appointment remaining on our schedule at the close of business. It is your responsibility to call or text to let us know that you will be unable to keep your appointment.

    6. AUTHORIZATION TO PAY BENEFITS: I authorize and direct said agency or insurance company to pay benefits, or insurance payments made on my behalf, directly to Covington Family Chiropractic LLC, for professional services rendered. I understand this in no way relieves me of my personal responsibility for paying my responsible portion.
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