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【Fee Schedule and Payment Policy for patients】

First Examination and Treatments or Re-Examination and Treatments
$150 and up

Regular treatment or visit
$80 and up

● Fees may vary depending on the treatments provided.
● Depending on your insurance policy, treatments may not be covered.
If you have MediCal/Medicaid, please visit a Medical Certified Doctor. We do not accept MediCal/Medicaid 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 coverage may differ after sending the claim to the insurance company.
If you have any questions, please call/text/e-mail us.
Tel: (213) 617-2228
Please do not use this form if it's for an Auto Accident or Workers Compensation
Do you intend to use your health insurance? *
Last Name *
First Name *
Date of Birth *
Sex(Biological) *
Marital Status *
Number of Children
Home Address *
Please do not forget to include APT# /UNIT #, Zip Code
Cell Phone Number *
E-mail Address *
Emergency contact information (Name&Phone Number) *
Occupation (Genre of work) *
Includes student, retired, housewife etc.
How did you hear about us? *
Who can we thank for referring you? (Name)
Patient's Condition
Please fill out your condition
What is your primary complaint? *
When did the complaint/symptoms start? (Date) *
How did your symptoms begin? *
If you have any other complaints, please describe.
Check where the pain is located *
Captionless Image
What makes it worse? *
What makes it better? *
Describe the pain or condition *
If the symptom radiates, please describe where
Intensity of the condition/pain level? *
No Pain
Intense Pain
Frequency of the symptom *
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? *
When does it get worse? *
Have you receive any treatment for this condition? *
If yes, describe the name of the practitioner and the date
Did you take any X-rays / MRI / CT for this condition? *
If yes, describe When, Where, and the Result
Have you had the same complaint in the past? *
If yes, when?
Check the conditions you're CURRENTLY experiencing *
Curent Internal Disease
Health History and Family History
Check the conditions that you had in this past 3 months *
Past physical symptoms and Injuries
Check the conditions you had in the PAST *
Check the conditions that your immediate FAMILY has had *
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 *
When and how did the incident happen?
List all medications in the PAST and PRESENT. (Name of the Drug, Symptom for, and Period) *
Are you Pregnant? (female only)
Clear selection
When is the due date?
How often do you exercise? *
What type of work activity do you do most? *
Do you take any nutritional supplements? *
Check on any of the following you do *
Recent weight *
Recent height *
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 *
We are open on Mon, Tue, Wed, Fri, and Sat. Closed on Thr, Sun, and Holidays
Date that you prefer to make an appointment *
What time would you like? *
How would you like to be contacted? *
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