Clone of Adult New Patient Paperwork

Additional Information
Parent/Guardian 2 (if applicable)

First NameLast Name
MotherFatherCourt-Appointed Guardian
Parent/Guardian 2 Cell
Please enter a valid phone number.Format: (000) 000-0000.
Sibling's names and ages (if applicable)
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Primary Doctor
Primary Doctor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Who can we thank for referring you?

Employment & Insurance Information
Guarantor Employer Name
Guarantor Employer Phone
Please enter a valid phone number.Format: (000) 000-0000.
Guarantor Occupation
Primary Insured Name

First NameLast Name
Primary Insured Birthdate

MonthDayYear
Date
Primary Insurance Company Name
Primary Insured Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Insured ID #
Primary Insured Policy #
Primary Insured Group #
Secondary Insured Name

First NameLast Name
Secondary Insured Birthdate

MonthDayYear
Date
Secondary Insurance Company Name
Secondary Insurance Company Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Insured ID #
Secondary Insured Policy #
Secondary Insured Group #

School-Age Children

(6-17 Years)
School/Home Information
What school does your child attend?
What grade is your child in?
BackpackBagOther
How heavy is your child's backpack (in pounds)
YesNo
List any sports, activities or hobbies you have?

Diet & Lifestyle

(All Ages)
What types of foods do you usually eat at meals?
What are your favorite snacks?
What is your favorite food?
How much water do you drink each day?
How much juice or soda do you drink each day?
How often do you eat fast food?
Do you take vitamins or supplements?
Do you have any food allergies? What are they?
EggsPeanutsCow's milkSoyFishWheat/Gluten
YesNo
Home Environment
Screen time per day TV/Video games/Computer/Tablet:
How many hours of sleep per night?
Are there smoker's in the home?
Are there pets in the home? What kind?
List any additional concerns that you have about your child's health or development:

Understanding Chiropractic Care
What We Do

We help restore your health naturally, without medication or surgery. This gives your body a chance to heal itself. Your results depend on many things, including what's causing your problem and your overall health.

Our Process

The doctor will check to see if you have subluxations (misalignments) in your spine that may be affecting your nerves. If the doctor finds subluxations, s/he can correct them by adjusting the spine and doing therapies that will help the muscles relax, reduce inflammation and help decrease your overall pain. When your spine is aligned properly, your nerves can work optimally and your body can heal.

Important: Every person is different. We cannot promise specific results because healing depends on your body and your overall health.

What You Should Know

Chiropractors are experts in spinal subluxations. If you have concerns about other health issues that are out of the doctor's scope of practice, s/he will make sure to refer or direct you to the correct provider.

Safety

Chiropractic adjustments are usually safe and helpful. In rare cases, some people should not get adjusted due to other health problems. This is why the doctor will do a thorough examination and determine if a chiropractic adjustment is the appropriate treatment.

Your Responsibility: Tell us about ALL your health problems so we can give you the safest care.

Results

We work to improve your health by adjusting subluxations in your spine. Since everyone is different, we cannot predict exactly how long treatment will take or guarantee results. Most people feel gradually better over time. We will do our best to estimate the length of your care based on your exam, x-rays (if needed) and response to your initial adjustments.
Agreement to Treatment
I have read and understand the information above about chiropractic care and consent to have my child treated.*
Type Name

First NameLast Name
Date

MonthDayYear
Date

Office Policies: What You Need to Know
Appointments
- If you arrive more than 10 minutes late, you will need to reschedule.
- Please check in at the front desk when you arrive.
- Bring a photo ID on your first visit.
- Bring your insurance card on your first visit and the first of every year.
- Bring any MRIs, CTs or X-rays you have from other doctors, if appropriate.
Payment & Insurance

If You Don't Have Insurance
- You will be asked to pay for your visit in full.
- We accept cash, checks, credit cards*, HSA Cards
- *Credit cards are subject to a 4% service fee.
If You Have Insurance
- Insurance is an agreement between you and your insurance company.
- We will file your insurance claims for free.
- We will check your benefits, but insurance companies don't always pay what they quote.
- You are responsible for:
  - Services your insurance doesn't cover
  - Deductibles (the amount you pay before insurance kicks in)
  - Co-pays (your portion of each visit)
- We are happy to give you an estimate on what you will owe for your visit based on your verified benefits.
Work Injuries
- Your employer's Worker's Compensation should pay.
- Tell your employer about the injury.
- Get your insurance company information from your employer.
- If your claim is not paid within 3 months, you are responsible for the balance.
Car Accidents
- Bring your auto insurance care AND health insurance card.
- Tell us if you have a lawyer
- Make sure you bring the Claim number from your insurance company.
- You have 4 payment options:
  1. Pay cash and we'll send reports when needed.
  2. We bill your auto insurance medical payment coverage.
  3. Your lawyer can send us a letter stating we will get paid when your case settles (we have a lien on your settlement).
  4. We bill your regular health insurance
Important: If your case isn't settled within 6 months of your care ending, you will personally be responsible for the balance.

Medicare
- Medicare will ONLY cover spinal adjustments if they deem they are medically necessary.
- Medicare pays 80% after you meet your deductible
- You pay the deductible plus 20%.
- Medicare DOES NOT COVER: (You must pay for these services.)
  - Exams
  - X-rays
  - All therapies
  - Supports or braces
  - Supplements
  - Wellness/Maintenance Care
Secondary Insurance
- Make sure to give us your secondary insurance card.
- We will file your secondary claims at no cost to you.
Important Reminders
I understand and agree to the Office Policies*
Type Name

First NameLast Name
Date

MonthDayYear
Date

Payment Agreement
I understand:
- My insurance is a contract between me and my insurance company.
- Frederick Family Chiropractic will file my insurance claims at no cost to me.
- If my insurance doesn't pay within 60 days OR if I stop coming for treatment, I must pay my balance immediately.
- I am responsible for the balance on my account.
Patient Signature:*
Type Name

First NameLast Name
Date

MonthDayYear
Date
Collection Agency Agreement

If your account goes to a collection agency, you agree to pay:
- The full balance of your account
- A 30% collection fee
- Attorney fees, if needed
- Court costs, if needed
By giving your phone number, you agree we can call or text you about your account, including using automated dialers.

I understand and agree to the Collection Agency Agreement.
Signature*
Type Name

First NameLast Name
Date

MonthDayYear
Date

Privacy Rights (HIPAA)
Patient Name*

First NameLast Name
Date

MonthDayYear
Date
I have received a copy of this office's Privacy Practices notice. I understand:
- How my health information will be used
- My privacy rights under HIPAA law
- I can request a full copy of the HIPAA Compliance Manual.
Signature*
Date

MonthDayYear
Date

Cost of Services

Updated: March 2026

Exams (Not covered by Medicare)

New Patient Exams	$95-$230 (depends on complexity)
Follow-up Exams	$77-$175 (depends on complexity)
Medicare requires:	A re-exam every 30 days
Other insurance requires:	A re-exam 1-2 times per year

X-rays (Not covered by Medicare

Neck X-rays	$52-$85
Mid/Upper Back X-rays	$50-$60
Lower Back X-rays	$55-$83
Miscellaneous (per set)	$50-$150

Adjustments

Spinal Adjustment	$55-$70
Extremity (shoulders, elbows, ankles, wrists, knees, ribs)	$35 (not covered by Medicare)

Therapies (Not covered by Medicare)

Therapy		Cost
Electrical Muscle Stim		$25
Ultrasound		$30
Decompression		$50
Exercise Instruction		$45

Medical Laser (Cash Only)

Single Treatment	$60
Same visit, each additional Area	$15
6 Treatment package	$300
12 Treatment package	$500

Brain Tap (Cash Only)

Initial Scan	Free
Brain Tap Session	$25
5 Brain Taps	$125
10 Brain Taps	$225
Follow-up Scan	$50
BrainTap Head Set	$550

I understand and agree to the cost of services.*
Type Name

First NameLast Name
Date

MonthDayYear
Date
Still have questions about costs? Ask the front desk.
Should be Empty:

New Patient Paperwork - Minor

Additional Information

Employment & Insurance Information

About the Patient

Main Complaint

Second Complaint (if applicable)

Pregnancy & Birth History

Mother's Pregnancy

Health History - Patient

Current Health Issues

Specific Health Questions

For Babies

Feeding

Development

Behaviors

For Toddlers & Preschool

Asthma

Bedwetting

Behavior

Development

Earaches/Ear infections

Headaches

School-Age Children

School/Home Information

Diet & Lifestyle

Home Environment

Understanding Chiropractic Care

Agreement to Treatment

Office Policies: What You Need to Know

Payment Agreement

Privacy Rights (HIPAA)

Cost of Services