Personal / Home Injury History

Patient Name: ___________________________________________________ Date: _________________________

Age: _____________ Birth Date: _____ / ______ / _____ ❑M ❑ F S.S.#: _________________________
Address: ______________________________________________________________________________________
City: ________________________________ State: ___ Zip: _________ Driver’s License #: ____________________
Insured: ___________________________ Address: ____________________________________________________
Name of Insurance Company: _____________________________________________________________________
City: ________________________________ State: _____Zip: ___________ Telephone #: ____________________
(If home injury, Home Owner’s Policy may be responsible for payment.)

Have you retained an attorney? ❑ Yes ❑ No Name of Attorney: ___________________________________

Address of Attorney: _____________________________________________________________________________
Date of Accident: _____ / _____ / _____ Time of Accident: _____________________ ❑ A.M. ❑ P.M.
Where did the accident happen? ___________________________________________________________________
Where were you taken after the accident? ____________________________________________________________
Where did you feel pain? ________________________________ Were you unconscious? ❑ Yes ❑ No
What are your present symptoms? __________________________________________________________________
Are your symptoms: ❑ Improving? ❑ Getting Worse? ❑ Same? ❑ Other? _____________________________
Name(s) of any other doctors consulted since your accident: _____________________________________________
Treatment received: _____________________________________________________________________________
How often did you receive treatment from the other doctor? ______________________________________________
Have you previously been injured in a similar manner? ❑ Yes ❑ No
PLEASE EXPLAIN FULLY HOW YOUR ACCIDENT HAPPENED: _________________________________________
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_________________________________________________________ MARK
PAIN
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AREA
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Date: _________ Patient Signature: ____________________________

+++ Burning 000 Stabbing

Date: _________ Patient Signature: ____________________________
--- Sharp III Consistent
FINANCIAL AGREEMENT
The purpose of this agreement is to clarify your financial responsibilities so we can devote our efforts to helping you to get the
best results in the shortest amount of time. The following are the most common services we provide:
P ROCEDURE P URPOSE WHEN P ERFORMED F EE
CONSULTATION Meet with the doctor, discuss your reasons for being First visit, new injuries, or No charge
here, review your case history new condition
EVALUATION / EXAM Ascertain the nature and severity of your health problem. First visits, new conditions, $60. -.$150
Assess and evaluate your new or current health status exacerbation's, and
and determine and appropriate course of action progress examinations
DIAGNOSTIC IMAGING Visualize the location of spinal problems and confirm As necessary for 1st visit, $25. -.$150.
(X-RAYS, SEMG AND other exam findings. re-injuries and progress
THERMAL SCANS) examinations
CHIROPRACTIC Reduce and remove the Vertebral Subluxation Complex As indicated by examination $35. - $55.
ADJUSTMENTS and evaluation
MASSAGE THERAPY Stress reduction, speed healing process, provide As indicated by examination 1/2 hour = $40.
muscular relief and increase circulation and evaluation and interest of 1 hour = $65.
patient 1 1/2 hour =$90.
NUTRITIONAL Access any nutritional imbalances or toxins that may be As indicated by examination $120. Initial
RESPONSE contributing to or compromising your body’s ability to and evaluation and interest of $35 Follow Up
TESTING heal and function at it’s optimal state patient

Forms of Payment
We accept cash, personal checks, Visa, Mastercard, Discover, Tradebank, and Barter For Less. Payment is expected at time of
service unless other arrangements have been made. Services may be paid for in advance.
Insurance / Third Party Pay
As a service to you, we will be happy to file your insurance claims and accept payment from your insurance company. After
verifying coverage, we will explain what portion of your bill is expected to be paid by your insurance company. It is important to
understand that you are still responsible to pay for services provided to you. If you would like our staff to check your chiro-
practic benefits, please present your insurance card when you return these forms and please sign after the following statements.
I authorize the release of health or other information necessary to process any claims. I also authorize payment of
chiropractic benefits to be paid to the Atlanta Natural Health Clinic . _____________________________________________
Special Arrangements
We have never denied anyone the benefit of chiropractic care due to their inability to pay our published fees. Individual contracts
can be designed to help specific financial needs. The most important thing to us is that people are given what they need.
Billing
Billing is taken care of at the front desk unless other arrangements need to be made.
Preferred Chiropractic Doctor (PCD)
Dr. Hurd is a participating provider with a national organization that legally allows us to reduce our fees for participating
members. PCD membership is available to all patients. Reduced fees are only applicable when insurance reimbursement is not
going to be used. Annual fees are $30. per individual and $45. per family. You can join here or online at www.bewell2.com.
Discounted prepayment plans are also available to PCD members.

I certify that all information provided is true and complete. I agree to pay the amount invoiced in full. I further agree to pay all costs of collection, including costs
of a collection agency if the account is turned over to a collection agency, and including 15% attorney's fees and court costs in the event this balance is turned over
to an attorney. It is agreed that this agreement will be governed under the law of the State of Georgia. The Atlanta Natural Health Clinic has the option of pursuing
an action under this agreement in any court of competent jurisdiction in the State of Georgia and I consent to jurisdiction in the State of Georgia.

Signature of patient: Date: