Noelle Nese Mercer Dc Logo

Phone : (213) 393-7035 • Email: noelle@noellemercer.com

New Patient Paperwork

Please fill out and send the form below if you are a new patient.

New Patient Paperwork

Please fill out and submit the fields below before your first appointment. 

    PATIENT INFORMATION

    Date of Birth

    Marital Status:

    MSWD

    CASE HISTORY

    List your chief complaints in order of severity:

    Is this condition getting progressively worse?

    YesNoConstantComes and goes

    Is this condition interfering with your:

    WorkSleepDaily Routine

    Other (please specify):

    Is this injury or illness work-related?

    YesNo

    Have you reported it to your employer?

    YesNo

    Is this injury or illness related to an automobile accident?

    YesNo

    Are you now or have you recently been in pain?

    YesNo

    If yes, describe the pain:

    DullSharpAchingStabbingBurningThrobbing

    Rate the pain on a scale of 1-10 (10 = unbearable):

    12345678910

    Does the pain radiate?

    YesNo

    If yes, where does it radiate?

    Down the armsDown the legs

    Any numbness or tingling?

    YesNo

    If yes, where?

    Does the pain come on:

    SuddenlyGradually

    Have you had any past injuries or accidents?

    YesNo

    If yes, please list:

    Have you ever experienced similar pain to which you now have?

    YesNo

    If yes, when?

    Is there a specific incident which you think caused your condition?

    YesNo

    If yes, describe the incident:

    MEDICAL HISTORY

    Check any of the following if relevant to your medical history:

    AlcoholismAnemiaArthritisAsthmaBackachesCancerConcussionConvulsionDiabetesDigestive DisordersDizzinessEpilepsyGerman MeaslesHeart DiseaseHepatitisHigh Blood PressureHIVMultiple SclerosisMuscular DystrophyNeuritisPolioRheumatic FeverTuberculosisVenereal Disease

    Are you allergic to any medication?

    YesNo

    If yes, what kind?

    Are you currently taking any medication?

    YesNo

    If yes, please list:

    Are you pregnant?

    YesNo

    Date of Last Menstrual Period:

    Pricing

    New patient - exam and treatment | (50-60 min) $220

    Follow up treatments - adjustment and tissue work | (20-30 min) $120

    Adjustment only | (10-15 min) $85

    Extended Follow Up Visits | (50-60 min) $220

    *rates for seniors and children may vary.
    ** extended follow up visits maybe scheduled upon request**

    CONSENT & AUTHORIZATION

    I agree
    I clearly understand and agree that all services rendered to me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered to me will be immediately due and payable.

    I agree
    I hereby authorize the Doctor to examine and treat my condition as she deems appropriate through the use of Chiropractic Health Care. I give authority for these procedures to be performed. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

    Disclosure & Consent Form for Chiropractic Adjustments and Care

    Any procedure intended to help may also do harm. While chiropractic examination and therapeutic procedures (including spinal adjustment, ultrasound, heat application, electrotherapy and manual muscle therapy) are usually considered very safe and effective, please understand that occasionally there are complications. While the chances of experiencing any of these complications are small, it is the practice of this clinic to inform our patients about them. This disclosure is not meant to scare or alarm you; it is simply an effort to make you better informed so that you may give or withhold your consent to the procedure.

    I understand and am informed that, in the practice of chiropractic, there are some risks to exam and treatment that include, but are not limited to, soreness, inflammation, soft tissue injury, dizziness, burns and temporary worsening of symptoms, fractures, disc injuries, strokes, dislocations, sprains, or no improvement of symptoms or pain. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interest. I further acknowledge that no guarantees or assurances have been made to me concerning the results intended from the treatment.

    I have read, or have been read to me, the above consent. I have had an opportunity to ask questions and all my questions have been answered fully and satisfactorily. By signing below, I consent to treatment. I intend this consent form to cover the entire course of treatment for my present condition and any further conditions for which I seek treatment.

    To be completed by patient or by patient's representative (i.e. if patient is a minor, physically or legally incapacitated)

    Payment and Insurance: Dr. Mercer is considered an “out of network” provider for most PPO plans. This allows Dr. Mercer to provide the treatment needed, not what your insurance company dictates. Fees will be collected at the time of service and a detailed receipt (aka “superbill”) will be provided upon request. The superbill can then be submitted by you for reimbursement from your insurance company. Each plan varies so it is best to check for out of network reimbursement rates, deductible and other details. In cases where your insurance plan is accepted, we will bill it for you. A credit card is required to be kept on file for any balances that may be due. This billing is done as a courtesy for you and in no way ensures payment. Ultimately your contract is between you and your insurance company. Cancellation Policy: Please respect my time and yours by canceling within 24 hours of your appointment time. Failure to do so may result in being charged in full for the session.