PAYMENT POLICIES

Soft Touch Chiropractic

 

1.       Signature below acknowledges that if my personal balance is not paid by my insurance company within 90 days I will pay my balance in full.

 

2. Payment for your first day services is due at completion of your office visit.

 

                                       ASSIGNMENT & RELEASE

I authorize release of information to family, physicians, employer and insurance companies.

I authorize the taking of photographs and x - rays to be used for treatment Purposes. I authorize the performance of other diagnostic and therapeutic procedures for treatment purposes. I authorize my insurance benefits (if any) to be paid directly to: SOFT TOUCH CHIROPRACTIC/DR. MASOUD SHAMAEIZADEH

19474 Rinaldi st

Northridge Ca 91326

I acknowledge that I am financially responsible for non covered services. I also understand that if I terminate my care any fees for professional services rendered me will be immediately due and payable.

 


 Focus exam                                                              $95.00

 


 Detail exam                                                             $325.00

 


Computerized spinal scan                                       $35.00

 


Discuss your exam and report of finding              $55.00 Scan included

 


Chiropractic spinal alignments                              $65.00 –$95.00

 


Physiotherapy $35 .00 for each Modality

 


Massage:  
30minutes $35.00  
60minutes$ 75.00   
90minutes $100.00  
Deep tissue $15.00 extra

 


Pastoral balance through neuromuscular reeducation     $35.00 

 


Nutritional Consultation                                                     $95.00  

 


Neuro-linguistic programming Coaching (NLP)              $85.00 per 45minutes

 


 Correspondence to insurance company and attorney $10.00 per page or $15per file .

 

Soft Touch Chiropractic reserves the right to have different fees for our promotions and coupons.

             

  Patient's

Signature:__________________________________ Date:____________

 

Guardian's

Signature:_________________________________ Date____________ 

 

 

 

Soft Touch Chiropractic

 

 

Consent to the performance of chiropractic adjustments

 

    I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and  on me ( or on the patient named below, for whom I am legally responsible) by the doctor of chiropractic (  Masoud Shamaeizadeh ) and by other doctors of chiropractic who now or in the future treat me while employed by , working or associated with or serving as back up for the doctor of chiropractic , including those working at the clinic .

 

   I understand the doctor of chiropractic (Masoud Shamaeizadeh) purpose of chiropractic adjustments and other procedures are to correct my Subluxations, Spinal Misalignments, and to improve my general health with out using of toxic drug or other invasive procedure. I understand that results are dependent on my compliances with the doctor’s recommendations.

             

  Patient's

Signature:__________________________________ Date:____________

 

Guardian's

Signature:_________________________________ Date____________ 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Soft Touch Chiropractic

 

 

 

 

 

 

                                                                 

 

 

 

Soft Touch Chiropractic

CONFIDENTIAL

REQUIRED FOR YOUR CASE HISTORY FILE

 

Name _________________________________________________________ Date _______________________

 

Address ___________________________________________________________________________________

 

City _________________________ State _____________ Zip Code ___________________________________

 

Home phone: ________________________ Cell: _______________________ Work:______________________

 

E-mail Address ______________________________________________________________________________

 

Social Security _____-______-_____ Birthday _______________ Driver’s License:____________  State ______

 

I’m interested in learning about the benefits of following the services:

 


  Chiropractic systematic alignments                             
  Physiotherapy & Massage                 
  Detox program

 


  Postural balance via neuromuscular re-education          
  Children’s chiropractic care               
  Food allergy Testing

 


  Nutritional Consultation                                             
  Acupuncture & herbal formulas         
  Hormonal balance

 


  Coaching (NLP)

 

Sex:
 M 
 F                         Marriage Status:
 Single  
 Married  
 Divorced  
 Widow |

 

Number of Children:________  Number of Pregnancies:_____ Occupation:___________________

 

Referred by:___________________________ Promotion Name: _________________________________

 

Would you like to schedule an appointment to discuss your exam and report of finding?
Yes
 No
 Not sure

 

Would you like to have a computerized scan of your spine?
Yes
 No
 Not sure

 

 

Person responsible for this account? ____________________________________________________________

 

Form of Payment:
 Cash 
 Credit Card 
 Check 
 Other                        
 Insurance:
 HMO
 PPO
 POS

 

Insurance Name: _________________Group #:____________________ ID Number________________________

 


 Medicare Only
 Medicare &HMO
 Medicare & PPO  |  Medicare ID Number________________________

 

Personal Injury Lean:
 Self representation
 Representation Attorney (Name of Attorney & phone #)

 

____________________________________________________________________________________________

 

Patient’s Signature:_ ___________________________          Date:____________                 Guardian’s Signature:____________________________ Date____________ 

 

 

 

 

 

 

 

 

SOFT TOUCH CHIROPRACTIC

CONFIDENTIAL HEALTH CONCERN HISTORY

1. What is your chief complaint that made you come in to our office today? Where are the areas of pain?__________________________________________________________________________

2. When did your problem and what precipitated it?_____________________________________

3. What do you do for fun and exercise?______________________________________________

4. Please describe the pain. Check the box

           A.)
Constant
 Frequent
Intermediate
Occasional.

           B.)
 Dull      
 Achy     
 Sharp.          
 gradual onset

           C.)
Severe   
 Mild      
 Moderate     
sudden onset     

5. What Part of day is your pain worse?
 Morning
Afternoon
Night  other_________

6 What makes the condition worse?_________________________________________________

7. What makes the condition better?__________________________________________________

8. Do you have any associated symptoms?
 Rash,
 Fever,
 Radiating pain
 other symptoms associated with this condition?______________________________________________________

 

9.Have you ever had any fractures? ” Yes When and where?________________­­­­­­____________

                                                          ” No.

10.Have you been involved in any accidents? If       ” Yes When and how?___________________

                                                                              ” No.

please explain.___________________________________________________________________

11. Have you had any previous chiropractic care?  ” Yes

          ” No

When and reason why?__________________________________________________________

12. Family history- please circle one.

Mother - alive/well/deceased.

          Any genetic disorders? ( example cancer, heart condition, diabetes, ect)_________________

Father - alive/well/deceased.

          Any genetic disorders? ( example cancer, heart condition, diabetes, ect)_________________

 

13. Do you have any brothers and sisters, if so how many?________________________________

 

14.  Name, address, and phone # of last Dr. who put you on a health development program?

 _____________________________________________________________________________

Are you healthier than you were 5 years ago ?         Yes
 No

Are you worse than you were 5 years ago ?            Yes
 No

15. If you behave as last five years, will you be healthier 5 years from now? Yes
No

 

 

 

 

 

 

 

 

 

 

 

 

                                                                     Soft Touch Chiropractic

 

Please indicate whether you have ever experienced stress in any of the following areas. Your answers will enable us to determine which factors have contributed to your present health concerns

 

ALLERGIES                                                          –  YES   –  NO          HEART CONDITION                        ’  YES      ’  NO                   

If yes, describe______________________________________

ANXIETY                                                                –  YES   –  NO          IMMUNE SYSTEM DISORDER      ’  YES      ’ NO                                           

ARTHRITIS                                                            –  YES   –  NO             INFERTILITY                                         ’  YES      ’  NO                   ASTTHMA                                                            –  YES   –  NO          KIDNEY DISEASE                            ’  YES      ’ NO                    

BACK PAIN                                                                                                  MENSTRUAL CRAMPS                       ’  YES     ’  NO                   

BLADDER PROBLEMS                                 –  YES   –  NO          MOOD SWINGS                                ’  YES      ’ NO                                     CANCER                                                                 –  YES   –  NO          NECK PAIN                                       ’  YES      ’  NO                   

CIRCULATORY/VASCULAR DISORDER   –  YES   –  NO         NUMBNESS/TINGLING                   ’  YES      ’  NO                                           

DEPRESSION                                                         –  YES   –  NO          OSTEOPOROSIS                                ’  YES      ’ NO                   

DIARRHEA                                                            –  YES   –  NO          SINUS TROUBLE                              ’  YES      ’ NO                                                               

DIGESTIVE PROBLEMS                                       –  YES   –  NO          SKIN CONDITIONS                          ’  YES      ’  NO                                  

DIZZINESS                                                             –  YES   –  NO          URINARY DIFFICULTY                   ’  YES     ’  NO                                            

 HEADACHES                                                        –  YES   –  NO          VERTIGO                                           ’  YES      ’  NO                   

HEARTBURN/REFLUX                                        –  YES   –  NO          OTHER                                               ’  YES      ’  NO                   

 

 

.

 

1.  Past history

Repeated/ prolonged antibiotic use                  ’  YES      ’  NO          Inhaler use                         ’  YES     ’  NO                   

Car accident                                                          ’  YES      ’  NO          Prescription medications   ’  YES     ’  NO                     

Childhood illness                                                 ’  YES      ’  NO          Surgery                              ’  YES      ’  NO                   

Fall/jump from a height <3 feet                          ’  YES      ’  NO          Vaccination                       ’  YES      ’  NO                   

Fall/jump from a height>3 feet                           ’  YES      ’  NO          Youth sports                      ’  YES      ’  NO

Extreme sports                                                   ’  YES     ’  NO           Workplace stress                ’  YES     ’  NO                                             

Head trauma                                          ’  YES      ’  NO  

 

 

 

 

Other traumas (physical on emotional):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                 

Soft Touch Chiropractic

 

Drug History

 

Please take your time and write Medication history that you have been taken for last five years

 

 

Prescription

 

 

 

 

 

 

 

-

 

 

Over the counter Drugs

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

 

Nutritional Supplements 

________________________________________________________________________________________________________________________________________________

                    

Doctor Masoud Strongly urges you to check with your MD about Stroke rate of your Medicines

 

Patient’s Signature