elemental medicine
​2915 SE Belmont, #1
Phone: 503.505.9677
​Fax: 503.427.9765
contact@elementalmedicinepdx.com
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    • Chiropractic FAQs
    • Forms and Fees
    • Specialties
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    • Acupuncture FAQs
    • Forms and Fees
  • Fascial Manipulation©
    • Forms and Fees
  • Schedule an Appointment
    • Contact & Hours
    • Insurance Billing FAQs
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 insured name, Name of insurance company, Member ID#


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
  • History of your issue.
  • Exam of one main problem area.
  • Diagnosis.**
  • Treatment: Chiropractic Manipulation to the problem area and either soft tissue massage (15 min.) or one modality (Electric Stimulation, Cold Laser, Ultrasound, Therapeutic Exercise).

Return Visits
  • $73 for a follow-up visit 

*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.

Online scheduling
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