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Forms: Chiropractic and Massage
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 ask that we have the ability to verify benefits prior to your first visit to ensure coverage. Prior authorization is not a guarantee of payment, and you the patient will ultimately be responsible for all charges incurred. Insurance coverage and co-pays vary. Please call 503-505-9677 ext 1 or email the following information from your insurance card to eblingchiropractic@gmail.com to have your insurance verified prior to your appointment. Full name, Date of birth, Insurance ID, Group #, Provider phone # 
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Fees: Chiropractic
Time of Service: When you pay in full at the time of your visit, the typical charges are as follows:* *Additional charges may apply based on the level of care required and will be disclosed prior to rendering treatment. Initial Visit $110
Return Visits
Now offering memberships so you can save! This special 1-year 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 Pay Pal, so all you have to do is let us know when you want to come in each month. Click here for full details. **If I do not think I can help you, the charge for the visit will be $30, not $110 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. Student Discount: 25% off above prices when paid at time of service for full time students. |
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