Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Home Phone (if any)
Work Number (if any)
Preferred Method of Contact
Employer/Profession (If retired, what did you do?)
Have you EVER been to a chiropractor?
If yes, when? And who was it?
Did you know that chiropractic is about more than just back pain, neck pain and headaches?
Yes! It affects the brain and all the organs!
No...does it really? That's awesome that it can affect the whole body!
Type option 3
Type option 4
Who may we thank for referring you?
Why this form is important:
In this office, our focus is on helping people to balance brain function so that their body can heal completely, from the inside out. The majority of problems people face are emotional stresses, physical trauma and toxic chemicals that can gradually accumulate over time to produce health problems. We seek to remove the causes of the issues you are dealing with, not merely cover them. Please complete this form as thoroughly as possible so that we can help you heal and the doctor will review it with you.
Coronary Artery Disease
Irritable Bowel Disease
Peptic Ulcer Disease
Renal (kidney) Disease
Do you have specific health concerns?
Yes (I will give more info in the next box):
No, my body works perfectly, I just want to keep it that way
If yes, please elaborate:
What level is your concern at now?
What's the worst it's been since it started?
Do you have a history of bone fracture, major accidents, surgery or severe injury?
Please give more details regarding any surgery fracture or severe injury:
How often do you engage in activity at the gym, at home or at work?
What supplements/medications are you currently taking? (If none, please state so)(If not sure of names, describe reason for taking)
Do you suffer from any known allergies?
What is the cause of your allergic reactions?
Please list in greater detail your specific allergy/allergic reactions (if any):
Please share regarding YOUR birth. Check ALL that apply:
Forceps were used during delivery
Vacuum extraction was used during delivery
Slow, drawn-out labor
Some other trauma not mentioned here (please explain with doctor)
I was adopted and don't know about my family history
Hyperlipedemia (High cholesterol)
Hypertension/Elevated blood pressure
Irritable bowel disease
Authorization for care of a minor (Under 18 years of age)
Only when I am here
Can be seen without me
I don't have any minor children
Children's names (If under 18 years old) and birthdays:
Office policy of Nxt Lvl Chiropractic
CLINIC HOURS - Open adjustment hours are posted in the office and are subject to change. Since no appointment is required, we cannot tell you when it will be busy in the office or what kind of wait period there will be at any particular time. Feel free to call/message the office to check on wait status before heading over. During open adjusting hours, the chiropractor may not generally be available for answering questions. An appointment is suggested if you need to discuss any concerns. Additionally, we may be closed for various reasons including holidays, continuing education seminars, and vacations. Schedule changes will be posted in the office, on our webpage, by text and on our Facebook page with as much advance notice as possible, so please follow us on Facebook at facebook.com/NxtLvlChiro. Text updates can be enrolled in at https://www.remind.com/join/nxtlvlc.
APPOINTMENT SCHEDULING & MISSED APPOINTMENTS - Appointments may be required only at the 1st visit due to the time needed for history review and the exam. Your doctor will tell you how many visits you need each week and what exercises, if any, you should be doing to allow for proper care. Walk-ins start with the 2nd visit. We expect Practice Members to take responsibility for their care. It is up to Practice Members to make up any missed visits. You will not be reimbursed or refunded for missed visits.
CHILDREN AND FAMILY -Once you understand that the brain and nervous system controls and coordinates all functions of the body and imbalances in the brain centers interfere with body function, we expect that you may want everyone in your family assessed. We extend an opportunity for you to have your family checked.
FINANCIAL AGREEMENTS - It is your payment that allows us to exist and continue providing high levels of professional care, maintain our facility, attend further continuing education and to compensate staff. If for any reason, you cannot keep your financial agreement, please inform us immediately to prevent any misunderstanding. If you have the desire to receive care in our office, we will make every attempt to make affordable arrangements. We have never refused care to anyone based on (in)ability to pay.
COMMUNICATION - I authorize NXT LVL CHIROPRACTIC to contact me by phone, text or email and must opt out in writing if I do not wish to be contacted
People heal at different rates. If you do not feel satisfied with your body’s responses, please make a consultation appointment to discuss this with your doctor. We want you to obtain the most from your care.
The successes of our office and the health of your loved ones greatly depend on your referrals. If there is someone you know that you would like to invite to our office, please let us know. Additionally, should you have someone in another town that you feel would benefit from an assessment by a chiropractor, we would be happy to provide you with names of doctors in their area.
Practice Member Expectations
I understand that the fee for my first visit may be included in the plan or package I agree to. I understand that family is defined at Nxt Lvl Chiropractic as the head of house hold and legal dependents. I agree that if I decline to accept doctor recommendations for care or if the doctor finds an issue contraindicating the chiropractic adjustment, I may still be responsible for that first visit’s charge.
I understand that no potential Practice Member(s) is/are adjusted without a completed history and assessment and that if imaging is warranted, no manual adjustments will be performed until imaging has been reviewed, whether it be imaging ordered at Nxt Lvl Chiropractic or imaging completed prior to a first visit at this office.
I understand following the 1st visit that I / we may come in anytime during Open Adjusting Hours for to be adjusted at least once per week. Twice per week is better.
I understand that Nxt Lvl Chiropractic is out of network with ALL health insurance companies. I understand that the fees at Nxt Lvl Chiropractic as detailed above are not considered reasonable or customary by insurance companies and that our services are not eligible for reimbursement, however, some Health Savings Accounts (HSA) may provide reimbursement and I understand that such reimbursement requests are my responsibility. I understand that insurance does not cover wellness or maintenance care.
I / We agree to notify Nxt Lvl Chiropractic’s staff of any changes to health status following first visit.
I understand that auto-debit payments are required to participate in the Membership Program, and that 30 days written notice is required to stop the auto-debit.
I / We understand that chiropractic care is not about relief of pain but that it is about balancing the brain, improving the function of my body within the limitations of matter and that many have experienced the side effect of pain relief from chiropractic care.
General. I understand that there may be other forms of care which I may wish or need to seek provided by other health care practitioners. I also understand that there may be significant risks of not seeking any care for my condition.I do not expect you to be able to anticipate and explain all risks and complications, or forms of treatment, and I wish to rely on you to exercise judgment within your scope of practice, based upon the facts known. I understand that in rare cases, underlying physical defects, deformities or pathologies may render me susceptible to injury. It is my responsibility to make known before and throughout the care whether I am suffering from any latent pathological defects, illnesses, or deformities that would otherwise not come to your attention, as well as any pathological defects, illnesses, or deformities I may be experiencing.
Possible Risks of the Care/Alternatives
Chiropractic Adjustment. As with any healthcare procedure, I understand that there are certain complications which may arise during chiropractic manipulation – however rare they might be, and that those complications include: fractures, disc injuries, dislocations, muscle strain, Horner's syndrome, diaphragmatic paralysis, cervical myelopathy and costovertebral strains and separations. Some types of manipulation of the neck have been associated with injuries to the arteries in the neck leading to, or contributing to, serious complications including stroke. Some patients will feel some stiffness and soreness following the first few days of treatment. I understand that fractures are rare occurrences and generally result from some underlying weakness of the bone. I also understand that stroke and other complications are also generally described as "rare" with some research stating it is unrelated.
Other/Potential Alternatives. I understand that other treatment options for my condition may include: Self-administered, over-the-counter analgesics and rest; medical care with prescription drugs such as anti-inflammatories, muscle relaxants and painkillers; hospitalization with traction; and surgery.
Contraindications to Adjustment / Procedures: I understand that you will not give me an adjustment / manipulation, x-rays, modalities, or therapies if you feel that such are contraindicated. In the event that the Care does not include such procedures, I have discussed all contraindications with you and fully understand them.
Definitions. “You” and “office” refer to any provider who renders care to me at the location above, and any off-site location associated with Nxt Lvl Chiropractic. “Care” includes all services I receive from you, both now, and in the future, including services related to other conditions.
By signing the line on the Intake Form, I signify that I have read this document in its entirety and understand the potential benefits and risks of Chiropractic Care at this office.
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