Chapin, SC

(803) 932-9399

Prosperity, SC

(803) 227-4891

Chapin - Case History Update

In order for us to serve you, and so that we may bring your original case history up to date, please provide us with the following updated information.

If yes, was it:
Has your insurance changed? If you have no insurance, select no.*
Please select at least one option

Insurance Data- Clinic policy requires payment arrangements be made on first visit. 

I understand and agree that health and accident insurance policies are an arrangement between an insurance a carrier and myself. Furthermore, I understand that the Doctor's Office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account on receipt. However, I clearly understand and agree that all services rendered me are charged directly to me ant that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable. 

I hereby authorize the Doctor(s) at Family Practice of Chiropractic to examine and treat my condition as he/she deems appropriate through the use of Chiropractic Health Care, and I give authority for these procedures to be performed. It is understood and agreed the amount paid the Doctor for x-rays is for examination only and the x- rays will remain the property of the office, being on file where they may be seen at any time while a patient of this office. The patient also agrees that he/she is responsible for all bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. 

I hereby authorize the Doctor(s) at Family Practice of Chiropractic to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered. This office does not turn away any patient due to their ability to pay. If you feel you might qualify for our Financial Hardship Policy notify the office immediately so that we can begin your qualification process.

Mark your Pain Point
Please note the intensity of pain. (0- no pain, 9-unbearable)*
Please select one option

Thank you for taking the time to fill out this form.

Chapin Office

Monday  

8:00 am - 6:30 pm

Tuesday  

8:00 am - 5:30 pm

Wednesday  

8:00 am - 6:30 pm

Thursday  

Closed

Friday  

8:00 am - 6:30 pm

Saturday  

Closed

Sunday  

Closed

Prosperity Office

Monday  

8:00 am - 5:30 pm

Tuesday  

Closed

Wednesday  

8:00 am - 5:30 pm

Thursday  

8:00 am - 5:30 pm

Friday  

8:00 am - 5:30 pm

Saturday  

Closed

Sunday  

Closed