1_Consent for Care-Adult

DR. MARIO CHAVEZ, D.C.
Date__________
Last Name____________________________ First_______________________ Middle Int._________ (PN :_________________)
E-mail Address: ________________________________________________May we send you our monthly email? Yes

No

Address: ___________________________________________________City:_________________State:___________Zip:_______
Home Phone (

)__________________ Cell Phone (

)_______________________Work Phone (

Which number would you prefer to have appointment reminders:

Home

Work

)_____________________

Cell

 None

Date of Birth____/____/____ Age_____ Children’s names and age__________________________________________________
Married: Yes

No

Spouse name:__________________________ Referred by:__________________________________

Occupation______________________________Employer_________________________________________________________
Are you pregnant? Yes

No

N/A

INSURANCE: We do not take insurance as payment. We will provide you with the insurance form to submit to your
insurance company for your reimbursement. Please give your insurance card to receptionist to make a copy.
1st Insurance Co.

Policy #

Group #

Insured’s Name

__________________________________________________________________________________________________________________________________

2nd Insurance Co.

Policy #

Group #

Insured’s Name

__________________________________________________________________________________________________________________________________

Insured’s Social Security. No. ________________________Medicare: Yes

No

No. _____________________________

Do you understand and accept these charges?
$150.00 X-rays and Film Analysis (Standard for First Appointment)
$50.00
Exam & Report of Findings (Standard for First Appointment)
$50.00 Office visit with a correction
$25.00 Re-evaluation (done every 12 visits)
$20.00 Office visit with no correction
How will payment be made?

 cash

check

 credit card

 other _____________

**Please note that all cancellations must give a 24-hour notice, or full amount of visit will be charged**
PATIENT’S SIGNATURE:
X
Signing this gives permission for care

Date

VITA NOVA SPINAL CARE, P.C. 
5437 SOUTH PRINCE STREET, LITTLETON, CO 80120 
PH: 303.798.VNSC   .    www.VitaNovaSpinalCare.com