|
Chiropractic Forms:
New patients are able to download these forms to complete prior to the initial visit. Click on the underlined links below and print out. Please complete them as thoroughly as possible, as this information is valuable for Dr. Ebling to provide the most appropriate care for you. Motor Vehicle Accident (6 pages) Please complete this form ONLY if you are seeking care related to an accident involving a passenger vehicle. New Patient Registration Packet (6 pages) These forms provide the office with all of your contact information, outlines the financial obligations and is the privacy policy and consent form. Also included is a health history form where you can indicate your current area of complaint, as well as a brief history of your past injuries, illnesses, medications and accidents. Major Medical Insurance If you would like to have the office bill your insurance, we must verify benefits at least 24 hours prior to your first visit to ensure coverage. Prior authorization is not a guarantee of payment, and you will ultimately be responsible for all charges incurred. Insurance coverage and co-pays vary. Please call 503-505-9677 ext 2 or email the following information from your insurance card to contact@elementalmedicinepdx.com to have your insurance verified prior to your appointment: Full name, Date of birth, Insurance ID, Group #, Provider phone # |
Fees: Chiropractic
Time of Service: When you pay in full at the time of your visit, the typical charges are as follows:* Initial Visit $140
Return Visits
Now offering memberships so you can save! - This special membership program is designed to help you receive the full benefits of regular chiropractic care and massage therapy without breaking the bank. You will be auto-billed through PayPal, so all you have to do is let us know when you want to come in each month. *Additional charges may apply based on the level of care required and will be disclosed prior to rendering treatment. **If I do not think I am the best fit for your current healthcare needs, there will be a $50 consultation fee and I will refer you to the appropriate specialist. Missed Appointments: There is a $50 charge for cancellations within 24 hours of your scheduled appointment time or no shows. Student/Senior Discount: Initial visits are $110 and follow-ups are $55 when paid at time of service for full time students and adults 65 or better. |
