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State / Province
Postal / Zip Code
You have permission to contact me by text/email
Employer/Profession (If retired, what did you do?)
Have you EVER been to a chiropractor?
If yes, when? And who was it?
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, but physical trauma and toxic chemicals can also gradually accumulate over time in effect short-circuiting the system causing break down and dysfunction in the body. 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.
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:
What supplements/medications are you currently taking? (If none, please state so)(If not sure of names, describe reason for taking)
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:
Please Check All That Apply
unable to concentrate
My glandular system is PERFECT
I eliminate toxins and waste PERFECTLY
unable to relax
tingling in extremities
My nervous system is PERFECT
My digestion is PERFECT
My muscular system is PERFECT
My circulation is PERFECT
I am willing and ready to see my body heal and allow it to work PERFECTLY
Yes, but with a comma after it
Duh, I am SO ready to be HEALTHY
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
Please Check All That Apply:
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 an adjustment – however rare they might be, and that those complications include: fractures, disc injuries, dislocations, muscle strain, Horner's syndrome, diaphragmatic paralysis, cervical myelopathy and costo-vertebral 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.
Contraindications to Adjustment / Procedures: I understand that you will not give me an adjustment if you feel that it is 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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