Weekly Symptom Checklist For Children Template

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(608) 836-8883
Patient Information
Date: ________________________
Name (last, first) _____________________________________________________________________
Address______________________________________________________________________________
City, State, Zip________________________________________________________________________
Phone (home) ________________ Phone (cell) _________________ Email ______________________
Spouse/Partner’s Name____________________
Sex ____ Age_____ Date of Birth____________
Children (
___________________ Occupation_____________ Employer/School______________
ages, names)
Whom may we thank for referring you to our office? __________________________________________
Are you covered by MEDICARE? Y / N
Medicare number______________________________
Are you covered by MEDICAID or BADGERCARE?
NOTE: we are not a Medicaid/Badgercare provider and you will not receive reimbursement.
Is this an AUTO ACCIDENT case?
Y / N
Is this a WORKER’S COMP case?
Y / N
Please provide contact information for the person at your place of employment
_____________________________________________________
that is authorized to accept liability for this case:
Fee Schedule – Chiropractic Services
Initial Exam and Office Visit (45-60 minutes):
$162
(Children under 18: $147)
Follow-up Office Visit (about 15 minutes):
$54
(Children under 18: $44)
Follow-up Office Visit, Extended (about 30):
$88
Our goal at Fenske Holistic Healthcare Center is to provide high quality, personal service that is responsive to the healthcare
needs of our patients. We require payment for services at the time they are provided because we feel this allows us to
focus on healthcare and not be distracted or influenced by the ever-changing time, monetary, and procedural restrictions of
insurance providers. A high quality, informed interaction between a patient and practitioner requires time not only for a
physical exam, but also for discussions regarding lifestyle and emotional concerns that are essential to providing
comprehensive, holistic care. Every patient is a unique individual and Dr. Fenske will take the time to get to know and treat
the individual in an effort to more effectively address the cause of health problems and not merely the symptoms. Please
note, insurance companies generally cover ‘structural’ Chiropractic work but not Functional Medicine/Nutritional
consultations, nutritional supplements, or preventative lab services. Any specific questions you may have about coverage
for our services should be directed to your insurance company.
Please note that prices are subject to change without notice, the duration of each visit is approximate, and 24-hour notice is
required to cancel an appointment without incurring a charge. Prices not only reflect the time spent with each patient but
also the advanced training, expertise, and effort required to treat complex health conditions. We accept payment by cash,
check, or credit card (MasterCard or Visa).
X
Patient Signature____________________________ Date ____________
Parent/Guardian ____________________________ Date ____________
(The signature of Parent/Guardian hereby authorizes Dr. Nicole Fenske to provide care for the minor child listed above.)

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