Pain 2 Wellness Center
3915 Cascade Rd
Atlanta, GA 30331
404-699-0966

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information


Personal Information
Contact Information
Feet Inches
   
 

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)

   

Draw Your Symptoms


Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

How did you find out about our office?


Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Insurance & Payment for Care


Primary Insurance
Secondary Insurance

If an auto accident, please provide:

Personal Health History


Family/Primary Physician

Separate details with "," comma as shown above.



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Health Problems & Concerns:


Please select all that you have had or currently have.

Authorization

I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I understand that I am responsible for payment of all deductibles and co-payments related to my care. I understand that if I have a balance for medical services not paid, I will make a minimum of $50.00 each month or 20% (auto-debit) of the outstanding balance whichever is greater. If my balance is not paid in a timely and monthly fashion, I promise to pay any and all service, collection, court, and attorney fees in the collection of my account. I further understand that if my treatment is associated with a personal injury or accident claim, all medical bills will be paid at 100% of the above fee schedule regardless of the outcome of my case. I also agree to Pain 2 Wellness Center filing a lien against the settlement of aforementioned case. I am aware that if my case is not settled 90 days after the end of treatment my account will be placed in collections. I understand that if a check or debit is returned for insufficient funds, I will be charged a $25.00 service charge.I further understand that if my insurance company declines payment, I authorize Pain 2 Wellness Center to file small claims on my behalf against my insurance company as a method of collection. I further understand that I will be present at the court date if needed.Financial Policy and Corrective Adjustment Plans We are committed to providing you with the best chiropractic care possible in a caring environment and have established our financial policies to achieve that goal. Details of your care plan will be discussed with you during you Chiropractic Report. To assist you with your healthcare investment, we provide the following payment options: • Cash - includes money orders and personal checks• Credit Cards – MasterCard, Visa, and American Express• Auto-Pay – an auto debit payment program that uses debit cards or credit cards. We offer weekly, monthly, or yearly payment plans.Health Insurance: If you have insurance that covers chiropractic, we will file all of the information for you. This includes your diagnosis, prognosis, and copies of your records or reports. Remember, you agreement with your insurance company is between you and them. If for some reason your insurance does not pay what we expect, you will be responsible for the balance. We file your insurance only as a courtesy for you. We will discuss this option with you during your Chiropractic Report. ALL DEDUCTIBLES AND CO-PAYMENTS must be paid prior to service. Special Situations: i.e. AUTO INJURY OR WORKERS COMPIf you choose to use insurance for a special injury claim, such as an auto accident or a workers compensation injury, your “normal insurance” will be “frozen” until such claim is closed. Your personal “Health Insurance” is not required to pay “third party claims”. We will then continue on the corrective plan we have chosen for you at that time.Order of Insurance Filing1. Med pay – Patient auto insurance2. 3rd Party Liability – At fault party3. Under or Uninsured Motorist – Patient auto insurance4. Personal Health Insurance – Patient health insuranceWellness Plans are only offered to individuals who have been examined by the doctor and who qualify for Wellness Care. Each individual must not have any personal injury, disease, or any serious health condition (not for treatment of disease or illness). Wellness Care is only considered on a case by case basis. Please inquire about rates and services.I have read and I understand the above policies.

Name of the Insured:
(Please Print)
_____________________________________________    
Patient's/Guardian's signature:
_____________________________________________
Date:
__________

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