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Personal / Home Injury History

Patient Name: ___________________________________________________ Date: _________________________

Age:_____________ Birth Date: _____/ ______ / _____ M F S.S.#: _________________________

Address: ______________________________________________________________________________________

City: ________________________________ State: ___ Zip: _________Drivers License #: ____________________

nsured: ___________________________Address: ____________________________________________________

Name of Insurance Company: _____________________________________________________________________

City: ________________________________ State: _____Zip: ___________ Telephone #: ____________________

If home injury, Home Owners Policy may be responsible for payment.)

Have you retained an attorney? Yes No Name of Attorney:___________________________________

Address of Attorney: _____________________________________________________________________________

Date of Accident:_____ / _____ / _____ Time of Accident: _____________________ A.M. P.M.

Where did the accident happen? ___________________________________________________________________

Where were you taken after the accident? ____________________________________________________________

Where did you feel pain? ________________________________ Were you unconscious? Yes No

What are your present symptoms?__________________________________________________________________

Are your symptoms: Improving? Getting Worse? Same? Other? _____________________________

Name(s) of any other doctors consulted since your accident: _____________________________________________

Treatment received: _____________________________________________________________________________

How often did you receive treatment from the other doctor? ______________________________________________

Have you previously been injured in a similar manner? Yes No

PLEASE EXPLAIN FULLY HOW YOUR ACCIDENT HAPPENED: _________________________________________

_____________________________________________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

_________________________________________________________

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Date: _________ Patient Signature: ____________________________

Date: _________ Patient Signature: ____________________________ +++ Burning 000 Stabbing--- Sharp III Consistent

MARK

PAINAREA

8/14/2019 Chamblee, GA Personal Injury History

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INANCIAL AGREEMENTe purpose of this agreement is to clarify your financial responsibilities so we can devote our efforts to helping you to get the

st results in the shortest amount of time. The following are the most common services we provide:

ROCEDURE PURPOSE WHEN PERFORMED FEE

ONSULTATION Meet with the doctor, discuss your reasons for beinghere, review your case history

First visit, new injuries, ornew condition

No charge

VALUATION/ EXAM Ascertain the nature and severity of your health problem.

Assess and evaluate your new or current health statusand determine and appropriate course of action

First visits, new conditions,

exacerbation's, andprogress examinations

$60. -.$150

AGNOSTIC IMAGING

-RAYS, SEMG AND

ERMAL SCANS)

Visualize the location of spinal problems and confirmother exam findings.

As necessary for 1st visit,re-injuries and progress

examinations

$25. -.$150.

HIROPRACTIC

DJUSTMENTS

Reduce and remove the Vertebral Subluxation Complex As indicated by examinationand evaluation

$35. - $55.

ASSAGE THERAPY Stress reduction, speed healing process, providemuscular relief and increase circulation

As indicated by examinationand evaluation and interest of

patient

1/2 hour = $401 hour = $65.

1 1/2 hour =$9

UTRITIONAL

ESPONSE

STING

Access any nutritional imbalances or toxins that may becontributing to or compromising your bodys ability to

heal and function at its optimal state

As indicated by examinationand evaluation and interest of

patient

$120. Initial$35 Follow Up

rms of Paymente accept cash, personal checks, Visa, Mastercard, Discover, Tradebank, and Barter For Less. Payment is expected at time ofvice unless other arrangements have been made. Services may be paid for in advance.

surance / Third Party Paya service to you, we will be happy to file your insurance claims and accept payment from your insurance company. After

rifying coverage, we will explain what portion of your bill is expected to be paid by your insurance company. It is important to

derstand that you are still responsible to pay for services provided to you. If you would like our staffto check your chiro-actic benefits, please present your insurance card when you return these forms and please sign after the following statements.

uthorize the release of health or other information necessary to process any claims. I also authorize payment ofiropractic benefits to be paid to the Atlanta Natural Health Clinic . ____________________________________________

ecial Arrangementse have never denied anyone the benefit of chiropractic care due to their inability to pay our published fees. Individual contractsn be designed to help specific financial needs. The most important thing to us is that people are given what they need.

linglling is taken care of at the front desk unless other arrangements need to be made.

eferred Chiropractic Doctor (PCD). Hurd is a participating provider with a national organization that legally allows us to reduce our fees for participating

embers. PCD membership is available to all patients. Reduced fees are only applicable when insurance reimbursement is not

ing to be used. Annual fees are $30. per individual and $45. per family. You can join here or online at www.bewell2.com.scounted prepayment plans are also available to PCD members.

rtify that all information provided is true and complete. I agree to pay the amount invoiced in full. I further agree to pay all costs of collection, including cosa collection agency if the account is turned over to a collection agency, and including 15% attorney's fees and court costs in the event this balance is turned ovan attorney. It is agreed that this agreement will be governed under the law of the State o f Georgia. The Atlanta Natural Health Clinic has the option of pursuiaction under this agreement in any court of competent jurisdiction in the State of Georgia and I consent to jurisdiction in the State of Georg

nature of patient: Date: