Steve J Costales Chiropractic, Inc
24741 Alicia Pkwy Suite D
Suite D
Laguna Hills, CA 92653
949-951-1160

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.)

   

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?




Personal Health History


Family/Primary Physician

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Family Health History


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(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:





Results:

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.




Authorization

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. 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. ASSIGNMENT OF BENEFITS: I hereby instruct my insurance company to pay by check and directly mail to: Steve Costales D.C., M.S., A.T.C. and/or Patricia McHone D.C. Chiropractic Sports Medicine 24741 Alicia Parkway Suite D Laguna Hills, CA 92653 For professional/medical expense benefits allowable, and otherwise payable to me under my current insurance policy as payment toward the total chargers for professional services rendered. This is a direct assignment of my rights and benefits under this policy. This payment will not exceed my indebtedness to the above mentioned assignee, and I have agreed to pay, in a current manner, any balance of said professional fees for non-covered services and/or fees, over and above the insurance payment or as required by my insurance policy. I grant the use of my signed statement of authorization with my signature for required insurance submissions. A photocopy of this Assignment shall be considered as effective and valid as the original. 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. PAYMENT POLICY: It is the policy of Chiropractic Sports Medicine to receive payment in full at the time services are rendered unless other arrangements have been made in advance. 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 and enrollment is not a guarantee of payment. Deductibles, co-payments and patient responsibility amounts are due at the time of service. Our office does not assume responsibility for verification of benefits and/or coverage. Please contact your insurance company before services are rendered. Any portion of the balance not paid by the insurance company due to patient co-pays, deductible amount, non-covered services, services deemed not medically necessary, doctor non-participation in a plan or any other reason for non or reduced payment is the responsibility of the patient or responsible party. HMO’s and other insurance plans that require authorization for treatment from the Primary Care Physician or other source must send written authorization for treatment to our office prior to services being performed. Self referrals and out of network benefits are usually not covered. Authorization does not guarantee payment by the insurance company. A statement of charges will be sent to the patient/responsible party showing the patient due balance. Patient due balances over 60 days will be subject to late fees. Delinquent balances may be referred to an outside agency for collection. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment. I have read the above policy, and understand that I am financially responsible for all medical services rendered.

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

Signature


Finalizing Form


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