Terms of Acceptance, Office Forms, Policies and Procedueres



When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.


Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.


Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation (misalignment).  Our chiropractic method of correction is by specific adjustment of the spine.  Chiropractors also adjust articulations of the extremities upper: shoulders, elbows, wrist, fingers; lower: knees ankles and toes.


Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.


Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of the nerve function and interference of the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential. (Also misarticulating extremity joints that cause nerve interference).


We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area.


Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.


I, _______________________ have read and fully understand the above statements.

(Print name.)

All questions regarding the doctor’s objectives pertaining to my care in this office have been answered to my complete satisfaction.


I therefore accept chiropractic care on this basis.



______________________________________                                      _____________

(Signature)                                                                                 (Date)


3915 Cascade Road SW, Suite 220



Fax 404-699-0988

Office Fee Schedule and Financial Policy


Service                                                            OFFICE FEES

Consultation                                                                             N/C-100

99201 – 99205            Initial Exam (Brief-Comp.)                    $100-$250

99211 – 99215            Est. Re-Exam (Brief-Comp.)                $50-$200

X-Rays (per view)                                                      BY REFERRAL

98940  Adjustment       (1-2 regions)                                        $51

98941              “           (3-4 regions)                                        $63

98942              “           (5 plus regions)                         $75

98943              “           (extremities)                                          $40

97035  Ultrasound 15 minutes or less                                        $45

97014  Electric Stimulation 15 minutes or less               $40

97012  Mechanical Traction 15 minutes or less `           $50

97110  Therapeutic exercises 15 minutes or less                        $65

97530 Therapeutic procedures 15 minutes or less                     $60

97535  Self Care Home Therapies 15 minutes or less    $77


Wellness & Corrective Adjustment Plans                Based on individual needs


Patient Statement of Understanding

I have read the codes and fees and understand the cost of my care with my treating doctor.  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.

I have read and fully understand the above financial terms, policies, and prices.



Patient Signature                             Date


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
  • CareCredit – offered as a separate line of credit with no annual fee or prepayment penalty
  • PayJunction – 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 COMP

If 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.


Wellness 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.


Patient Signature                                      Date






  1. I hereby assign your office my right of recovery for any insurance benefits providing me coverage that would pay for my treatment expenses, including but not limited to, motor vehicle medical payment coverage, health insurance benefits or any other insurance I am eligible to receive.


  1. In the event any insurance company obligated by contractual agreement to make payment for the treatment charges I incur with your office refuses to make such payment upon demand by you, I hereby assign and transfer to you the cause of action that exits in my name as you see fit and further authorize you to compromise, settle, or otherwise resolve said claim as you see fit.


  1. I direct payment be made directly to your office for any sum I owe for treatment charges by a.) Any insurance company obligated to make payment on my behalf, and b.) By my attorney out of the proceeds of any settlement, verdict or award due me, based in whole or in part upon the charges made for your services.


  1. You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney, or adjuster in order to process any claim for reimbursement of charges incurred.



Patient Signature:  ________________________________      Date: __________________




By signing above, the co-payment and/or

Deductible for my chiropractic treatment

Would be a financial hardship on me.



THE UNDERSIGNED being ATTORNEY (S) of record for the above patient does hereby agree to observe all the terms of the above agreement and agrees to withhold such sums from any settlement, judgment, award or verdict as may be necessary to adequately protect said doctor above named including cooperating with the doctor to file whatever interpleaded of declaratory action as is necessary to protect the doctor, the client and the attorney from any ethical or legal violations.


 Attorney Signature: ______________________________       Date: __________________             


Patient Goals


[ ]         Pain Relief   

­__ Auto Accidents , __Workers Compensation, __Whiplash, __ Headaches, __Neck Pain, __Back Pain, __Disc Problems , __Sciatica, __Fibro-Myalgia, __Carpel Tunnel, __Scoliosis __Stress

[ ]         Vertebral Subluxation Correction

Vertebral- [Ver-te-bral] concerning the vertebral bones of the spine.

Subluxation- [Sub-lux-a-tion] Less than a complete dislocation of a joint with nervous system interference.

“Vertebral Subluxation Complex” is the underlying cause of many health problems.

[ ]         Improve Activities of Daily Living

Problems with repetitive movements such as lifting, pushing, pulling, and sweeping, digging, bending or twisting can be improved.  Carrying weights on one shoulder or one hip should be periodically redistributed or a backpack or other method can be used.  Posture correction and implementation of ergonomic work stations. Avoid working in a seated position with elbows unsupported as it places significant strain on trapeziums, scalene and other frequently injured muscle groups.

[ ]         Family Wellness Lifestyle

Good nutrition, exercise, chiropractic care, and other preventive measures are part of a wellness lifestyle. While chiropractic care can help with the integrity or your nervous system, remember the emotional and spiritual aspects of true wellness. A wellness approach to better health means adopting a variety of healthy habits for optimum function on all levels-physical, mental, social, and spiritual.

[ ]         Improve Diet and Nutrition (Weight Loss)

Proper nutrition, accompanied by exercise, posture, rest and periodic spinal adjustments, is a key to preventive health care. The over consumption of foods high in fat, cholesterol, refined and processed sugars, salt and alcohol increases the probability of suffering from cardiovascular diseases, diabetes and some forms of cancer.

That is why at Pain 2 Wellness Center we suggest specific nutritional supplements for each patient. Ask for your specific nutritional assessment TODAY.

[ ]         Sports Performance and Evaluation

The lumbar spine is the most frequently injured area of the spine. Sports injuries among youngsters are often ignored as “growing pains”. Regular chiropractic checkups can help avoid problems seen later in adults. Help prevent sports injuries by proper stretching, warm-up and cool-down exercises, and by staying fit. Proper spinal function is essential for peak performance at work or play.

[ ]         Maintenance of Active Lifestyles for Seniors

The general population is going to chiropractors in record numbers. Seniors, the fastest segment of the population is no exception. A recent study published in Topics in Clinical Chiropractic of a randomized clinical trial showed data that found chiropractic geriatric patients were “less likely to have been hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community.”

Print Name ____________________              Date ___________



Sign _________________________

I  _______________  request that Pain 2 Wellness Center have access to the following medical records in order to provide the best health care possible.


Please list below the names, addresses, and phone numbers of ALL the doctors you have visited:


Name                          Address                                                          Phone Number








































Electronic Health Records Intake Form

In compliance with requirements for the government EHR incentive program

First Name:________________________ Last Name:_________________________

Email address:  _________________@_________________

Preferred method of communication for patient reminders (Circle one):  Email / Phone / Mail

DOB:   __/__/____     Gender (Circle one):   Male / Female Preferred Language:  __________________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked

CMS requires providers to report both race and ethnicity

Race (Circle one):   American Indian or Alaska Native / Asian / Black or African American / White (Caucasian)  Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one):  Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name

Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies?

Medication Name


Onset Date

Additional  Comments

I choose to decline receipt of my clinical summary after every visit(These summaries are often blank as a result of the nature and frequency of chiropractic care.)

Patient Signature: _____________________________________________   Date:________________

For office use only

Height: _________       Weight:____________    Blood Pressure:______ /______



3915 Cascade Road


Atlanta,Georgia  30331

(404) 699-0966

Fax: 404-699-0988



I understand that this organization originates and maintains health records which describe my health history, symptoms, examination, test results, diagnoses, treatment, and any plans for future care or treatment.  I understand that this information is used to:


  • Plan my care and treatment
  • Communicate among health professionals who contribute to my care
  • Apply my diagnosis and services, procedures, and surgical information to my bill
  • Verify services billed by third-party payers
  • Assess quality of care and review the competence of healthcare professionals

In routine healthcare operations


I further understand that:


  • A complete description of information uses and disclosures is included in

A Notice of Information Practices which has been provided to me

  • I have a right to review the notice prior to signing this consent
  • The organization reserves the right to change their notice and practices
  • Any revised notice will be mailed to the address I have provided prior to implementation
  • I have the right to object to the use of my health information for directory purposes
  • I have the right to request restrictions as to how my health information may be used

Or disclosed to carry out treatment, payment, or health care operations

  • The organization is not required to agree to the restrictions requested
  • I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon


ÿ  I request the following restrictions to the use or disclosure of my health information.







Notice Effective Date







___Accepted      ___ Rejected





____________________________________          ________________________________

Patient Signature


____________________________________                                    ____________________




____________________________________          ________________________________

Signature of Legal Representative                                                                                            Title


Date________________________________          ___Accepted      ___ Rejected




Patient Name ____________________________  Birth date__________________


Please discuss any questions or conditions with the Doctor before signing the consent.


I hereby request and consent to the performance of chiropractic adjustments and the other chiropractic procedures including various modes of physical therapeutic modalities and diagnostic x-rays by the doctor or chiropractor(s) named above.


I have had the opportunity to discuss with the doctor and/or with other office or clinic personnel the purpose and the benefits of the chiropractic adjustment and other treatments outlined below.  Alternatives to treatment have been reviewed.


Though chiropractic adjustments and treatments are usually beneficial and seldom cause any problem.  I understand and am informed that there are some risks to treatment.  Risk include, but are not limited to: fracture, disc injuries, strokes, dislocations and sprains.


I understand and agree to receive the following treatment protocol:



q  Hot/Cold Fomentation 97010

q  Electrical Stimulation 97014

q  Ultrasound 97035

q  Mechanical Traction 97012

q  Spinal Manipulation 1-2 Regions 98940

q  Spinal Manipulation 3-4 Regions 98941

q  Spinal Manipulation 5 Regions 98942

q  Ex-Spinal Manipulations 98943

q  Manual Therapy 97140

q  ParaffinBath97018

q  Infrared Therapy 97026

q  Massage Therapy 97124

q  Neuromuscular Re-Ed Therapy 97112

q  Therapeutic Activities 97110

q  Therapeutic Procedures 97530

q  Self-Care Home Management 97535


TREATMENT GOALS:           Reduce symptoms, Increase functional capacity and Return to ADL

Therapeutic Phase 1: Acute inflammatory, reduce inflammation, muscle spasm and pain

Therapeutic Phase 2:  Repair and Remobilization; functional scar formed and increase pain free ROM

Therapeutic Phase 3:  Remodeling and Rehab; increase coordination and strength, endurance and work   capacity


C__________         T___________        L___________        S____________      IL___________      Ext__________

Treatment Frequency:

No. (#) of days per week: ________No. (#) of Weeks: ______ No. (#) of treatments ________

Re-Evaluation Date: ______________                                Exp. Total # of treatments _______

I understand that chiropractic is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized.  I have had the opportunity to read this form and ask questions.  My questions have been answered to my satisfaction.  I consent to the proposed treatment.


_______________________________________________  ____________________

Signature of Patient, Guardian, or Personal Representative                      Date


_______________________________________________  _____________________

Please print name of Patient or Personal Representative            Relationship to Patient



Witness Signature____________________________                    ________________



Doctor’s Signature___________________________                      Date ________________




  1. Please sign in on our sign-in sheet.


  1. Fill out the patient progress report as instructed and place the document in the designated area.


  1. Hours of operation are Monday, Wednesday, and Friday 9:00 AM till 7:00 PM, Thursday 11:00 AM till 7:00 PM and Saturday 10:00 AM till 12:00 PM (by appointment only). Please hold your preferred treatment time; we request that all appointments be made 2 weeks in advance whenever possible. This will save you and the office time and eliminate waiting.


  1. All new problems, re-exams, consultations, and diet and exercise programs are to be discussed during extended treatment hours, not during your preferred treatment time. If a new problem develops, an accident occurs, etc. you should call and reschedule an appointment from preferred hours to extended hours when more time would be available.
  2. Our office accepts payment by the week (first day of your treatment/week), month, or year. Payment each visit would cause our patients to make out unnecessary checks and cause waiting to occur.


  1. Your RESULTS are obtained based on the number of visits/week not per month. Therefore, it is vital you hold to your schedule. If an emergency arises, we ask you to notify us as soon as possible. An official make up appointment will be assigned and reserved for you so that you can know in advance when to make up a missed appointment.


  1. If you request us to direct bill your insurance company, we ask you to leave a credit card on account to cover our costs in the event you should receive the insurance check for our services. The credit card would only be used if you fail to provide our office with the funds within 5 days of receiving them.






  1. Reduce Waiting Treatment Hours:  TREATMENT ONLY
  2. Consultation/Examination Hours: Report of Findings, New Patient Examinations, Re-Evaluations, Reassessments.
  3. Advanced Treatment Hours: As needed for none responding to care patients (there will be extra charge for these patients.).


By signing below I understand and agree to the patient policies and scheduling procedures.


__________________________________                             _________________

Patient Signature                                                                                                     Date

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