905-541-3099; 289-925-4928

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CHIROPRACTIC CARE

Service: / Patient Fee:
Initial Consultation including first treatment
Subsequent Chiropractic Visit
Chiropractic Visit & Laser Therapy
Re-evaluation: On or before every 24th visit or 90+ days since last treatment
Orthotic Devices*
Orthotic Shoes/Sandals*
Compression Stockings / $80.00
$40.00
$45.00
$45.00
$400.00
$550.00
$150
*50 % deposit required on all orthotic devices, shoes and sandals

We accept: CASH, INTERAC, VISA, and MASTERCARD

*Cash and Interac are preferred methods of payment

WSIB: yes/no Date of accident: WSIB claim #______

MVA: yes/no Date of accident: Claim adjuster name/contact number: ______

Policy # ______

Private Insurance Company: ______

La Vita Sana Chiropractic does not third party bill (i.e. bill your insurance on your behalf), therefore fees recoverable from extended health benefits are the patients own responsibility. It is the policy of La Vita Sana Chiropractic Clinic that payment is required at the time of services rendered. No accumulation of fees is permitted.
NOTE: IF AN APPOINTMENT IS CANCELLED WE REQUIRE 24 HOURS NOTICE. IF LESS THAN 24 HOURS NOTICE IS SUPPLIED THE FULL FEE FOR YOUR MISSED VISIT WILL BE CHARGED ALONG WITH YOUR NEXT TREATMENT FEE.
When would you like to receive Receipts/Statements for Services?
A receipt each visit: When I ask for one:
End of each month: December 31st:

Date: ______Signature: ______

La Vita Sana Chiropractic: 1242 Garner Road W., Ancaster, Ontario, L9C 3K9

The data on this confidential form is essential if we are to tender the best professional care. We appreciate your co-operation in filling it out so that we have accurate records. PLEASE PRINT CLEARLY- THANK YOU

NAME: ______Sex: M / F

Home address: ______

City/Town: ______Postal Code: ______

Home Phone: ______Business: ______

Cell Phone: ______Referred by: ______

Email Address: ______Occupation: ______

Date of Birth: Day: ______Month: ______Year: ______

Medical Doctor: ______Phone Number: ______

PLEASE INITIAL IF YOU CONSENT TO COMMUNICATION BETWEEN YOUR CHIROPRACTOR AND MEDICAL DOCTOR: ______

Reason for today’s visit:

¨ Emergency ¨ New Injury ¨Old Injury ¨Chronic Pain ¨Wellness Visit

Is the visit due to a Motor Vehicle Accident? ¨Yes ¨No

Is this a WSIB case and has it been reported to your employer? ¨Yes ¨ No

Are you in pain: ¨Yes ¨ No

Rate your pain with the following scale:

Low Discomfort 1 2 3 4 5 6 7 8 9 10 Intense

Did your injury occur during: ¨Work ¨Sports/Play ¨Auto Accident ¨Routine/Household Activity

When did your condition/accident occur? ______

Please explain what happened? ______

Is your condition getting worse? ¨Yes ¨ No ¨ Constant ¨ Comes & goes

Is your condition interfering with your: ¨Work ¨ Sleep ¨Daily Routine If so how? ______

Has this or something similar happened in the past: ¨Yes ¨No Explain: ______

Using the attached symptom diagram, please indicate all affected areas

Have you been treated by a medical physician for the pain? ¨Yes ¨ No If so where? ______

Have you been treated by a chiropractor? ¨Yes ¨No


Have you been treated by a physiotherapist? ¨Yes ¨No

La Vita Sana Chiropractic: 1242 Garner Road W., Ancaster, Ontario, L9C 3K9

Are you taking any of the following medications? ¨Nerve Pills ¨Pain killers (including aspirin) ¨Muscle Relaxants ¨Blood Thinners ¨Tranquilizers ¨Insulin ¨Other(s) ______

Do you or have you had any of the following diseases, medical conditions, or procedures?

Y N Heart Attack/Stroke
Y N Artificial Valves
Y N Shingles
Y N High/Low Blood Pressure
Y N Ulcers/Colitis
Y N Difficulty Breathing / Y N Heart Surgery/Pacemaker
Y N Alcohol/Drug abuse
Y N Cancer
Y N Psychiatric Patterns
Y N
Fainting/Seizures/Epilepsy
Y N Birth Control Pill
Y N Are you Pregnant?
How many weeks? / Y N Heart Murmur
Y N Venereal Diseases
Y N Frequent Neck pain
Y N Rheumatic Fever
Y N Sinus Problems
Y N Lower back problems
Y N Anticoagulants / Y N Congenital Heart disease
Y N Hepatitis
Y N Glaucoma
Y N Headaches
Y N Severe/Frequent
Y N Emphysema/Asthma
Y N Artificial bones/joints/implants
Y N Haemophiliac / Y N Mitral Valve Prolapse
Y N Anemia/Diabetes
Y N Kidney Problems
Y N Tuberculosis
Y N Arthritis
Y N Allergies

Please list any surgeries with dates and/or any other serious medical condition(s) not listed above:

______

List any past serious accidents with dates: ______

We invite you to discuss with us any questions regarding our services. The best services are based on a friendly, mutual understanding between provider and patient.

Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid in full within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges, and any expense incurred in collecting your account.

I authorize the staff to perform any necessary services needed during diagnosis and treatment I also authorize the provider to release any information required to process insurance claims.

I understand the above information and guarantee this form was completed to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.

I understand the benefits of collaboration between my health care providers. If I were to be under the treatment/care of more than one staff member at La Vita Sana Chiropractic, then I authorize collaboration between parties to provide me with the best health care possible.

My extended health care covers:

Chiropractic ¨ $______Naturopathy ¨ $______

Physiotherapy ¨ $______Orthotics ¨ $______

Massage Therapy ¨ $______Compression hosiery ¨ $______

Signature: ______Date: ______

¨Adult patient ¨Parent or Guardian ¨Spouse