Wellness Experience
9180 Forest Hill Blvd.
Wellington, FL 33411
(561) 333-5351

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:

Employment Information


Current Symptoms


If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

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.



Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Family Health History


Separate details with "," comma as shown above.

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

Social History & Life Choices:


 

Chiropractic Experience

Please select all that apply.

Other:

If yes…

What was the reason for those visits?

Doctor's Name:

Approximate date of last visit:

Reason for this Visit

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

Does this concern interfere with:





Results:

Auto Accident










Visited a Hospital or Doctor?






Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:

Authorization

I acknowledge that I was provided a copy of the Notice of Privacy Practices and that I have read them or declined the opportunity to read them and understand the Notice of Privacy Practices. I understand that this form will be placed in my patient chart and maintained for six years.Private pay patients are expected to provide payment in full at the time of service. We accept cash, check and all major credit cards. We also require a copy of your driver's license. Patients using general insurance are required to fill out a confidential form as well as provide us with your driver's license and insurance card on the first visit. If you do not provide your insurance information within 5 business days of your first visit, you will be switched to a private pay plan. We will call the insurance company to verify your benefits, however, that does not guarantee payment for services that are provided. We will bill your insurance as a courtesy. You are responsible for all deductibles, co-payments and non-covered services at the time services are rendered.If you have been involved in an auto accident, we require a copy of your accident report, auto insurance and all health insurance information. If an attorney is involved, you must return a signed doctor's lien form within 7 business days of your first visit. All accident patients must seek medical treatment within a 14 day period from the date of the accident. Non-emergency chiropractic visits are subject to a $2,500 limit. Emergency chiropractic visits are subject tot a $10,000 limit. If no treatment has been rendered within a 14 day period, you are responsible for full payment.Dr. Randall Laurich is a participating Medicare provider which means we submit your claims to Medicare. Medicare patients are subjected to a $183.00 yearly deductible that must be met before your co-insurance will be applied. Once the deductible is met, Medicare will pay 80% of the allowable fee and you are responsible for 20% of the associated fees unless you have a secondary insurance. The spinal adjustment is the only covered service under Medicare. Maintenance care is not covered by Medicare, nor are the required exam fee of $35.00. Any non-covered service must be paid for at the time of service.Please be aware that any patient account 31 days past due will accrue all responsible collection costs and/or attorney fees. All accounts will be assessed 1.5% per month on the outstanding balance from the date of service. I understand that there is no guarantee that insurance companies, prepaid heath plans or Medicare will cover or pay for all of my charges. I understand that I am responsible for all remaining charges.We require that all massage patients must make any massage cancellations 24 hours prior to their scheduled appointment. Cancellations made within that 24 hour window are subject to a $35.00 cancellation fee.

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

Signature


Finalizing Form


  1. Submit Form!