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【Fee Schedule and Payment Policy for patients】

First Examination and Treatments or Re-Examination and Treatments
$120 and up ($150 and up, from January 2019)

Regular treatment or visit
$70 and up ($80 and up, from January 2019)

● Fees may vary depending on treatments provided.
● Depending on your insurance policy, treatments may not be covered.
If you have Medical/Medicaid, please visit Medical Certified Doctor. We do not accept Medical/Medicaid Insurance.


【INSURANCE】
Your health insurance may not cover chiropractic care.
If you would like to verify your health insurance coverage for chiropractic care, please use the verification form on the website.


Please note that we can not guarantee your insurance coverage and may differ after claiming to the insurance.
If you have any question, please call/text/e-mail to us.
Tel: (213) 617-2228
Email: info@bestclinicla.com

Please do not use this form if its for an Auto Accident or Workers Compensation
Which treatment would you like to receive? *
Required
Do you intend to use your health insurance? *
Last Name *
Your answer
First Name *
Your answer
Date of Birth *
MM
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DD
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YYYY
Sex(Biological) *
Martial Status *
Number of Children *
Your answer
Home Address *
Your answer
APT# / UNIT #
Your answer
City & Zip Code *
Your answer
Cell Phone Number *
Your answer
E-mail Address *
Your answer
Emergency contact information (Name&Phone Number) *
Your answer
Occupation (Genre of work) *
Your answer
How did you hear about us? *
Required
Who can we thank? (Name)
Your answer
Patient's Condition
Please fill out your condition
What is your primary complaint? *
Your answer
When did the complaint/symptoms start? (Date) *
MM
/
DD
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YYYY
How did your symptoms begin? *
Your answer
If you have any other complaints, please describe. *
Your answer
What makes it worse? *
Your answer
What makes it better? *
Your answer
Describe the pain or condition *
Required
If the symptom radiates, please describe where
Your answer
Intensity of the condition/pain level? *
No Pain
Intense Pain
Frequency of the symptom *
None
100% Always
How much does the pain interfere with your daily activities (work, social, or household chores)? *
Not at all
100% Always
How is your symptom changing? *
Required
When does it get worse? *
Required
Have you receive any treatment for this condition? *
Required
If yes, describe the name of the practitioner and the date
Your answer
Did you take X-rays / MRI / CT for this condition? *
Required
If yes, describe When, Where, and the Result
Your answer
Have you had the same complaint in the past? *
If yes, when?
Your answer
Health History and Family History
Check the conditions you're CURRENTLY experiencing *
Required
Check the conditions that you had in this 3 months *
Required
Check the conditions you had in the PAST *
Required
Check the conditions that your immediate FAMILY has had *
Required
Are you experiencing episodes of Stress, Anxiety, or Depression? *
Are you currently under treatment for it? *
Check on anything that you had in the past 10 years *
Required
When and how did the incident happen?
Your answer
List all medications in the PAST and PRESENT. (Name of the Drug, Symptom for, and Period) *
Your answer
Are you Pregnant? (female only)
When is the due day?
Your answer
Lifestyle
How often do you exercise? *
What type of work activity do you do most? *
Required
Do you take any nutritional supplements? *
Required
Check on any of the following you do *
Required
Recent weight *
Your answer
Recent height *
Your answer
Certificate
I certify that the above information is complete and accurate to the best of my knowledge. I agree to notify this doctor immediately whenever I have changes in my health condition in the future *
This form was filled out and certified by *
Appointment
We are open on Mon, Tue, Wed, Fri, and Sat. Closed on Thr, Sun, and Holidays
Date that you prefer to make an appointment *
Required
What time would you like? *
Required
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