Welcome to Skywalk Chiropractic & Massage
Our practice is committed to providing the highest quality patient care and helping you to achieve your personal health goals.
The following form is for you to complete before your first visit. This provides a general report of who you are, your past health history, and the current condition for which you are seeking treatment that your health care provider can review in preparation for your first visit.
You may choose to complete this from the comfort of your own home or office OR you may also complete it upon arrival for your first visit. If you prefer the latter option, please be prepared to arrive at least 10-15 min early for your appointment.
Select options below indicating age at diagnosis and other relevant details.
Musculoskeletal
Neurological
Cardiovascular
Respiratory
Digestive
Sensory
Integumentary
Endocrine
Genitourinary
General
What is the most significant thing you can do to improve your health?
How committed are you at achieving your maximum health potential?
How do you want us to handle your problem?
Please read the following carefully before signing.
Office Policies
Please review these important policies regarding our office.
Your Account
Please be advised that you are responsble for the fees for all services rendered to you and charged to your account unless other arangements have been made, such as direct billing of services to Maitoba Public Insurance, Workers Compensation Board of Manitoba, Manitoba Health, or a 3rd party insurance. All fees are due the day the services are provided and may be paid by cash, debit, or credit card. All accounts left outstanding for more than 30 days will be subject to a 4% interest charge compounded monthly.
Private Insurance
As a courtesy and convenience to you we submit claims to your insurance company directly whenever possible. We do require that you pay your co-payment and/or deductible at the time services are rendered. Please note that all insurance companies and plans are different. We will work our hardest to insure the accuracy of your claims, but payment by insurance is never guaranteed. Your insurance policy is a contract between you and the insurance company. We are not a party to that contract which may prevent us from submitting claims, obtaining the necessary information, or assigning payment. We will do our best to help you, but you are ultimately responsible for the costs of treatment.
Massage Appointment Cancellation Policy
Massage therapy appointments require 24-hours notice for any changes or cancellation of the appointment to avoid a cancellation fee of 50% of the services booked. This cancellation policy does not apply to Chiropractic appointments, however we do ask that you give as much notice as possible if you need to make any changes as a courtesy to our other clients.
* Please read and agree to the terms
Signature
Today's Date: 25 Jan 2020