Please fill out the information below to the best of your capability. The more details we have about you and your lifestyle, history, and surroundings, the better we can understand how to treat you. Get in touch with us at [email protected] with any questions, or call the office at (949) 359-8385.

We are looking forward to you experiencing the magic of being Well Connected!

New Minor Patient (Insurance)

Patient Information

Full Legal Name *

Date of Birth *

Gender

Male

Female

Phone *

Email *

Address *

City *

State *

Postal code *

Date *

Whom may we thank for referring you to us?

Is this injury/illness related to an automobile accident?

Have you ever had Chiropractic Care before?

Initial Problem Record

What is your main complaint or problem?

How did this begin?

When did this begin?

Complaint #2

Complaint #2 - When did this begin?

Complaint #2 - How did this begin?

List Doctors (name & phone number or email) consulted for condition(s):

What makes your problem better?

What makes your problem worse?

Has this happened before?

This problem bothers me:

Do you have any other related or unrelated complaints you would like to address?

Medical History and Present Medical Condition Questionnaire

Musculoskeletal

Back trouble/pain

Neck trouble/pain

Joint injury/pain/swelling

Carpal tunnel syndrome

Additional Health and Lifestyle Questions

Are you experiencing any stresses, mood problems, relationship difficulties, or substance-related problems for which you would like to resource or referral information on a confidential basis?

If yes, please explain:

Do you occasionally use or are you currently taking any prescription or over-the-counter medications?

List name, dosage, and the reason for the medication:

I drink

beers (per week)
ounces of hard liquor (per week)
ounces of wine (per week)

Are you currently or have you ever been a cigarette smoker? If yes, please explain how many packs per day/how many years below.

When were your most recent health maintenance screening tests?

Cholesterol - Results?
Mammogram - Results?
Pap smear - Results?
PSA (prostate) - Results?
Sigmoidoscopy - Results?

Have you had a change in the size or color of a mole, or a sore that would not heal in the past year?

Please describe any weekly exercise or physical activities including any exercise at work:

Would you consider yourself to have a well balanced diet? Please explain below if indicated.

Trauma History

Have you ever been in an auto accident/fender bender?

If yes, please describe nature of accident and age accident occurred:

Have you ever had any concussions/loss of consciousness?

If yes, please describe nature of concussion/loss of consciousness and at what age:

Have you ever had any surgeries? Please list below:

Financial Agreement

Read carefully and choose the plan that best fits you.

Plan #1 – Cash, Check or Charge (Non-Insurance) - The new patient appointment is $500, 2nd appointment is First Correction & Report of findings is $130, regular follow-up visits are $80, Re-exam is $125, Infant or Pregnant is $180 without x-rays, Medicare first adjustment $101 - $105 depending on coverage.

Plan #2 – Insurance - Please be aware that we are an out-of-network provider, with the exception of TriWest and Multiplan. If you have insurance that covers out of network chiropractic care, we will bill your out-of-network chiropractic benefits directly if the deductible is $1500 or less. It is your responsibility to determine the out of network chiropractic benefits (we will provide a detailed form that gives all the information you need from your insurance company to determine if you have out-of-network coverage.) It is required that you fill out the document completely after you talk to your insurance company if you wish to go through insurance at Well Connected Chiropractic. It is vital to have this page completely filled out to ensure we have the most up to date and correct information regarding your insurance plan. Until we receive insurance payments for your dates of services, regular follow up visits will remain $80.

Plan #3 - Auto Injury/ Personal Injury - We will need your MedPay benefits/health insurance information and attorney’s name as well as their telephone number (if applicable). Even when working with an attorney on a lien, we may collect copays at each time of service. In the event the lien is voided or MedPay benefits are exhausted, you are responsible for the bill in its entirety immediately. If while under treatment you decide to retain an attorney and your MedPay benefits are distributed to your attorney, you will be responsible for payment in full immediately at time of service going forward and for any outstanding balance the attorney has collected from your MedPay benefits.

PAYMENT PLAN OF MY CHOOSING

Notices - Please read and initial next to each line

All new patients will receive a re-exam approximately 8 weeks from their initial visit to determine progress and the direction of further treatment. This exam is $100, and all other re-exams during further treatment will be subject to the exam fees.
Appointments that are not cancelled at least 24 hours prior (M-Th 9am-5pm) will be subject to a no show/late cancellation fee.
There will be a $250 no show fee for failure to show up to your new patient appointment. We require at least 48 hours for any scheduling changes.
There is a 4% credit card processing fee for all transactions made with a debit or credit card. If you wish to avoid this credit card processing fee, you can pay with cash, check or Zelle. In the event of a refund, the 4% credit card processing fee is non-refundable.
Office policy is for all patients to keep a credit/debit card on file regardless of payment method.
In the event your account is sent to collections, there will be a 40% increase in your balance to cover service fees for the collection agency.

No-Show Policy

We are so thankful for the amazing people we have the opportunity to serve. We are always investing in ways to make the experience for our patients as positive as possible. Not showing up to your scheduled appointment not only affects our efficient system, it also affects other patients seeking care at Well Connected. It is vital that all patients show up to their scheduled appointments on time. If you need to cancel or reschedule a chiropractic or massage appointment, please notify us at least 24 hours before your scheduled appointment. You can call or text the office at (949) 359-8385. If no one answers or you call after hours, please leave us a detailed voicemail or send a text message. Doing so will count as sufficient notice if done at least 24 hours before your scheduled appointment. Any cancellations made after the end of the business day preceding your next appointment will be subject to a late cancellation fee. (5:30 pm Monday-Thursday)

Cancelling same day or not showing up to your scheduled new patient chiropractic appointment results in a $250 no show fee.

Cancelling same day or not showing up to your scheduled chiropractic appointment results in a $50 no show fee.

Cancelling same day or not showing up to your scheduled chiropractic exam appointment results in a $100 no show fee.

Cancelling same day or not showing up to your scheduled massage appointment results in paying THE ENTIRE FEE for the massage.

Cancelling same day or not showing up to your scheduled craniosacral therapy massage appointment results in paying THE ENTIRE FEE for the craniosacral therapy massage.

Office policy is for all patients to keep a credit/debit card on file.

Patients who prefer to pay with cash or check are still required to keep a card on file.

When a no-show fee is added to your account, we will reach out to you via call, text, and email to inform you.

We will process your card for the appropriate fee by the end of the next business day.

**Patients on an auto accident lien, or using med-pay will still be charged the fee for a missed appointment, and will not get reimbursed from the third-party payer.

Please initial and sign below to acknowledge you understand this policy.

Keeping a credit/debit card on file is necessary in the event I am responsible for a no-show fee.
I understand my credit/debit card on file will be charged the appropriate fee by the end of the next business day.
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $250 FEE FOR NEW PATIENT APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $50 FEE FOR CHIROPRACTIC APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to a $100 FEE FOR CHIROPRACTIC EXAM
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to PAYMENT IN FULL FOR MASSAGE APPOINTMENT
I am aware that in the event I need to change or cancel a scheduled appointment and I do not call, text, or email [email protected] at least 24 hours before my scheduled appointment I am subject to PAYMENT IN FULL FOR CRANIOSACRAL THERAPY APPOINTMENT

HIPAA Notice

THIS NOTICE DESCRIBES HOW CHIROPRACTIC AND MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In the course of your care as a patient at Well Connected Chiropractic we may use or disclose personal and health related information about you in the following ways;

1. Your protected health information, including your clinical records, may be disclosed to another health care provider or hospital if it is necessary to refer you for further diagnosis, assessment or treatment.

2. Your health care records as well as your billing records may be disclosed to another party, such as an insurance carrier, agent, adjuster, HMO, PPO, or your employer, if they maybe responsible for the payment of services provided to you.

3. Your name, address, phone number, and your health care records may be used by our office only to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information.

You have a right to request restrictions on our use of your protected health information for treatment, payment and operations purposes. Such requests are not automatic and require the notice to this office.

Your name, address, telephone number, e-mail address and health records may be used to contact you regarding appointment reminders, information about alternatives to your present care, or other health related information that maybe of interest to you. If you are not home to receive an appointment reminder or other related information, a message may be left on your answering machine or with a person in your household.

You have a right to confidential communications and to request restrictions relative to such contacts. You also have the right to be contacted by alternative means or at alternative locations.

We are permitted and may be required to use or disclose your health information without your authorization in these following circumstances:

1. If we provide health care services to you in an emergency.

2. If we are required by law to provide care to you and we are unable obtain your consent after attempting to do so.

3. If there are substantial barriers to communicating with you, but in our professional judgment we believe that you intend for us to provide care.

4. If we are ordered by the courts or another appropriate agency.

You have the right to receive an accounting of any such disclosures made by this office. Any use or disclosure of your protected health information, other than as outlined above, will only be made upon your written authorization. If you provide an authorization for release of information you have the right to revoke that authorization at a later date. Information that we use or disclose based on this privacy notice may be subject to re-disclosure by the person to whom we provide the information and may no longer be protected by the federal privacy rules. We normally provide information about your health to you in person at the time you receive chiropractic care from us. We may also mail information to you regarding your health care or about the status of your account. If you would like to receive this information at an address other than your home or if you would like the information in a specific form please advise us in writing.

You have the right to inspect and/or copy your health information for as long as the information remains in our files. In addition you have the right to request an amendment to your health information.

Requests to inspect, copy or amend your health related information should be provided to us in writing. We are required by state and federal law to maintain the privacy of your patient file and the health protected health information therein.

We are also required to provide you with this notice of our privacy practices with respect to your health information.

We are further required by law to abide by the terms of this notice while it is in effect. We reserve the right to alter or amend the terms of this privacy notice. If changes are made to our privacy notice we will notify you in writing as soon as possible following the changes. Any change in our privacy notice will apply for all your health information in our files. If you have a complaint regarding our privacy notice, our privacy practices or any aspect of our privacy activities you should direct your complaint to: If you would like further information about our privacy policies and practices please contact: You also have the right to lodge a complaint with the Secretary of the Department of Health and Human Services. If you choose to lodge a complaint with this office or with the Secretary your care will continue and you will not be disadvantaged by this office or our staff in any manner whatsoever.

This notice is effective as of April 2003, and any alterations or amendments made hereto will expire seven years after the date upon which the record was created.

My initials acknowledge that I have received a copy of this notice.

Please initial, acknowledging you've read and understand the above HIPAA policy

Enter initials here

Please list other people (i.e. spouse, child, friend, personal trainer, attorney, massage therapist, acupuncturist, nutritionist) with whom you authorize Well Connected Chiropractic to discuss your chiropractic care and health information.

Consent to Treat a Minor

Dated in Missioin Viejo, California on:

I hereby authorize Elizabeth S. Hoefer, D.C. to administer chiropractic care as she so deems necessary to my son/daughter,

By signing below, I hereby authorize that all of the information stated about myself is truthful, and that I have read and agree to the above statements outlined in this form:

Initial Patient Record

Financial Agreement

No Show Policy

HIPAA Notice

Consent to Treat a Minor

Patient Name *

Signature of Patient or Person Acting on Patients Behalf *

Clear

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I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.