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Chiropractic & Wellness - New Patient Forms

Our new patient forms may be filled out online or they can be downloaded, printed, and filled out. Fax us your printed and completed form(s) or bring it with you to your appointment.

If you fill out the forms prior to your appointment you will need only to arrive at our office 5 minutes prior to your appointment time.

If you choose not to fill out the forms in advance, please plan to arrive at our office 30 minutes prior to the scheduled appointment time in order to complete the paperwork.

In order to download the forms you must have AdobeReader® installed on your computer. If you do not already have AdobeReader® Click Here to download.

Notice Of Patient Privacy Policy

Complete New Patient Forms Online

Forms may be filled out using a computer, notebook or Ipad. They cannot be filled out on and Android device or Iphone.

An electronic signature is required at the end of the form before the form the can be uploaded. To sign the document simply write your signature in the box using your mouse or mouse pad. The signature cannot be typed in.

We require all new patient forms to be filled in electronically.  If you are unable to complete the forms on line please plan to arrive 20 minutes earlier than your scheduled appointment time in order to complete forms in our office. 


Let us get started filling out this form.

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants. It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 
Gender*
Please select one option
Marital Status*
Please select one option

Employer Information

Emergency Contact

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option
If job related, have you made a report of your accident to your employer?
What is the complaint type?*
Please select at least one option
How did the injury or complaint start?*
Please select one option
Frequency of pain?*
Please select one option
What is quality of discomfort?*
Please select at least one option
What aggravates the symptoms?*
Please select at least one option
What do you have difficulty performing due to this specific complaint? (Choose all the apply)*
Please select at least one option
Activity of daily living most affected*
Please select at least one option
If the discomfort radiates, where does travel to? Otherwise, choose NON-RADIATING.*
Please select at least one option
Is complaint getting better, worse or staying the same?*
Please select one option
Rate the pain on a scale of 1-10*
Please select one option
Symptom relieved by?*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Have you received any past care for this complaint?*
Please select at least one option
Have any recent diagnostic images or tests been performed?*
Please select one option
Activity of daily living most affected*
Please select at least one option
Do your symptoms increase while performing your normal work duties?
If yes, please select the amount below that you feel your symptoms increase at work:
What are your specific therapeutic goals?*
Please select at least one option
Place an X on the image below, where you feel pain, numbness or tingling:

Patient History

What cardiovascular issues are you experiencing?*
Please select at least one option
What Head and ENT issues are you experiencing?*
Please select at least one option
What respiratory issues are you experiencing?*
Please select at least one option
What gastrointestinal issues are you experiencing?*
Please select at least one option
What genitourinary issues are are you experiencing?*
Please select at least one option
What endocrine issues are you experiencing?*
Please select at least one option
What dermatological or hematopoietic issues are you experiencing?*
Please select at least one option
What allergy or sensitivity issues are you experiencing?*
Please select at least one option
What is your surgical history?*
Please select at least one option
Have you ever had any pins, plates, screws, or any other hardware placed in your body?
Past history of accidents or trauma?*
Please select at least one option
Drugs and medication(s)?*
Please select at least one option
Patient's Immediate Family Health History?*
Please select at least one option

FOR WOMEN ONLY:

Are you pregnant?
Are you nursing?
Are you taking birth control?
Do you experience painful periods?
Do you have irregular cycles?
Do you have breast implants?

Health Habits & Conditions

Work?*
Please select at least one option
Social habits?*
Please select at least one option
Exercise routine?*
Please select at least one option
Diet and nutrition?*
Please select at least one option
Do you wear

Financial Policy

Insurance Coverage

Your insurance is an agreement between you and your insurer, not between your insurer and this office. Coverage for chiropractic and therapy services varies from insurer to insurer and plan to plan. Most insurance policies require the beneficiary to pay a co-insurance, co-payment, and /or deductible. For example: if you have a deductible of $100, and your insurance pays 80%, you are responsible for 20% of all charges incurred during the year after you have paid your $100 deductible. Our office will call your insurer to verify your benefits, however, this is NOT a guarantee of payment from your insurer.

Payments

In order to help you determine your responsibility toward your payment for services, please read the following, and initial your preference for the method of payment of your account. Please notify this office if the status of your insurance changes.

Private Pay: (please initial)

Who should receive bills for payment on your account?*
Please select at least one option

Time of Service Fee Schedule and Financial Policy

Service Fee

Consultation

No Charge

Initial Exam/

$100-$165

Re-Exam

$50-$120

Adjustments

$39-46



Important: All clients are responsible for full payment for the first visit (unless other arrangements have been made in advance.)

Today's payment will be made by:*
Please select at least one option

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES 

I have been given a copy of (Chiropractic and Wellness Center)'s Notice of Privacy Practices ("Notice"), which describes how my health information is used and shared. I understand that (Chiropractic and Wellness Center) has the right to change this Notice at any time. I may obtain a current copy by contacting Chiropractic and Wellness Center Privacy/Security Official, or by visiting the (Chiropractic and Wellness Center) web site.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

Missed Appointments

At the Chiropractic & Wellness we do not cluster or double book. The appointment time schedule is yours and your time alone. We also take pride in keeping to schedule. Forgotten and otherwise missed appointment have a serious impact on the office and patients who otherwise could have been seen at that appointment time.

It is our policy of Chiropractic & Wellness Center to assess a $25 missed appointment fee for chiropractic services to patients who cancel within 4 hours before their appointment, and a $50 missed appointment fee for massage therapy to patients who cancel appointments with less than a 24-hour notice.

I understand that all health services rendered to me and charged to me are my personal financial responsibility. I understand and agree to the conditions in this policy. I fully consent to receiving treatment from any or all practitioners in this practice.

Consent to be contacted by Email or Text

hereby consent and state my preference to have my physician, Dr. Mary Jo Johnson, and other staff at Chiropractic and Wellness Center communicate with me by email or standard SMS/text messaging, in addition to or to replace leaving phone messages, regarding various aspects of my health care, which may include, but shall not be limited to, test results, appointments, and billing.

I understand that email and standard SMS/text messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email and standard SMS/text messaging regarding my medical care might be intercepted and read by a third party.

I give my permission to leave both appointment reminders AND my private health information at the following (please fill in the ones you agree to):

I give permission to contact me, relative to appointment reminders only, by the following methods:

Thank you for taking the time to fill out this form.

REVIEW WAVE ELECTRONIC SIGNATURE TERMS AND CONDITIONS

Updated September 10, 2020

THESE ELECTRONIC SIGNATURE TERMS AND CONDITIONS ARE INCORPORATED BY REFERENCE INTO THE REVIEW WAVE TERMS AND CONDITIONS AND ARE LEGALLY BINDING.  By using the Review Wave E-Signature Service, you accept and agree to the terms of these terms and conditions (the "Terms").  Should any conflict arise between these Terms and the Review Wave Terms of Service (the "Standard Terms"), these Terms shall control with respect to the subject matter herein.  Both you and Review Wave may be referred to herein individually as a "Party", and collectively as the "Parties".

  1. THE E-SIGNATURE SERVICE.
    • Service Description. Review Wave's electronic signature service (the "Service") allows you to signify your agreement with legally binding agreements electronically, in lieu of a pen-and-ink signature on a physical hardcopy.  The Service is a "Review Wave Service" for the purposes of interpreting the Standard Terms.
    • Authorized Users. The Services are available only to individuals who can form legally binding contracts under applicable law.  The Services are not available to persons under the age of majority in their jurisdiction, and in no case to persons under the age of 18.  In order to use the Services, you must be identified by a unique email address.  Two or more natural persons may not use the Services using the same set of credentials.
    • Appropriate Conduct. You agree not to use the Services for any illegal or unauthorized purpose and agree to comply with all applicable domestic and international laws, statutes, ordinances, and regulations relating thereto.  You further warrant and agree that your use of the Services does not violate any relevant laws, regulations, legislation, or other applicable rules of any applicable authority.  You are solely responsible for determining the suitability of the Services for your particular purpose.

You agree not to (attempt to) modify, adapt, or hack the Services.  You agree not to engage in any activities that would create a false association with the Services.  You agree that Review Wave has sole and absolute discretion with respect to the determination of whether your use of the Services is authorized.

  • Authorized Use. You shall use the Service solely for your internal business or personal purposes, and in no case shall you make the Services or any portion thereof available to any third-party.
  1. WARRANTY DISCLAIMER AND LIMITATION OF LIABILITY.
    • Warranty Disclaimer. The Services are provided to you without warranty of any kind, whether express or implied.  REVIEW WAVE SPECIFICALLY EXCLUDES AND DISCLAIMS WARRANTIES OF TITLE, MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE, QUIET ENJOYMENT, NON-INRFINGEMENT, AND ANY WARRANTIES ARISING OUT OF COURSE OF DEALING OR USAGE OF TRADE.

USE OF THE SERVICES IS DONE AT YOUR OWN RISK.  REVIEW WAVE ASSUMES NO RESPONSIBILITY FOR ANY LOSS OF YOUR DATA OR CONTENT OR ANY ERRORS OR OMISSIONS IN ANY CONTENT, OR FOR ANY LOSS OR DAMAGE OF ANY KIND INCURRECT AS A RESULT OF THE USE OF THE SERVICE.

  • Damages Limitation. REVIEW WAVE SHALL NOT BE LIABLE FOR ANY INCIDENTAL, SPECIAL, EXEMPLARY, OR CONSEQUENTIAL DAMAGES, INCLUDING LOST PROFITS, LOSS OF DATA, LOSS OF GOODWILL, THE COST OF SUBSTITUTE PRODUCTS OR SERVICES, OR FOR ANY DAMAGES FOR PERSONAL OR BODILY INJURY OR EMOTIONAL DISTRESS ARISING OUT OF OR IN CONNECTION WITH THESE TERMS, OR FROM THE USE OF OR INABILITY TO USE THE SERVICES, WHETHER BASED ON WARRANTY, CONTRACT, TORT (INCLUDING NEGLIGENCE), PRODUCT LIABILITY, OR ANY OTHER LEGAL THEORY, AND WHETHER OR NOT REVIEW WAVE HAS BEEN INFORMED OF THE POSSIBILITY OF SUCH DAMAGE, EVEN IF A LIMITED REMEDY SET FORTH HEREIN IS FOUND TO HAVE FAILED OF ITS ESSENTIAL PURPOSE.
  • Limitation of Liability. IN NO EVENT WILL REVIEW WAVE'S AGGREGATE LIABILITY ARISING OUT OF OR IN CONNECTION WITH THESE TERMS AND YOUR USE OF THE SERVICES EXCEED THE AMOUNT RECEIVED BY REVIEW WAVE FROM YOU IN THE SIX (6) MONTH PERIOD PRECEDING THE ACTION GIVING RISE TO THE CLAIM.  THE LIMITATIONS OF DAMAGES SET FORTH ABOVE ARE FUNDAMENTAL ELEMENTS OF THE BARGAIN BETWEEN REVIEW WAVE AND YOU.  SOME JURISDICTIONS DO NOT ALLOW THE EXCLUSION OR LIMITATION OF LIABILITY FOR CONSEQUENTIAL OR INCIDENTAL DAMAGES, SO THE ABOVE LIMITATION MAY NOT APPLY TO YOU.
  • German Customers. Review Wave's liability to you if you are domiciled in Germany is limited as follows:
    • Review Wave shall be fully liable for intentional and gross negligence, as well as for any damages arising from injury to life, body or health caused by Review Wave. In the case of liability for slight negligence, Review Wave shall be liable only for breach of a material obligation ("Cardinal Duty") and any such liability shall be limited to typical, foreseeable damages and shall not include liability for lack of economic results, loss of profit, or indirect damages. A Cardinal Duty in the meaning of this Section 2.4 is an obligation, the fulfillment of which is essential to the performance of these Terms and on the fulfillment of which the contracting party may therefore rely.
    • If you are a consumer, nothing in these Terms affects your rights under mandatory German law and these Terms will be interpreted, construed, and enforced in all respects in compliance with mandatory consumer protection laws of Germany. Notwithstanding anything to the contrary herein or within the Standard Terms, if you are a consumer, you may submit a claim to enforce your rights under these Terms to the competent courts in Germany.
  1. CUSTOMER OBLIGATIONS.
    • Personal Data. You warrant that your use and collection of any personal information or data provided while using the Services complies with all applicable data protection laws, rules, and regulations.  You acknowledge that Review Wave may process such personal data in accordance with its privacy policy [LINK TO POLICY].
    • Customer Acknowledgements and Warranties. By using the Service you consent to do business electronically.  You hereby represent and warrant to Review Wave that: a.) you have all requisite rights and authority to use the Services under these Terms and to grant all applicable rights herein; b.) you are solely responsible for all use of the Services associated with your credentials; c.) you are solely responsible for maintaining the confidentiality of your account credentials; d.) your agrees to immediately notify Review Wave of any unauthorized use of your account of which it becomes aware; e.) you agrees that Review Wave will not be liable for any losses incurred as a result of a third party's use of your Account, regardless of whether such use is with or without its knowledge and consent; f.) you will use the Services for lawful purposes only and subject to these Terms; g.) any information you submits to Review Wave is true, accurate, and correct; and h.) you will not attempt to gain unauthorized access to the Services, other accounts, computer systems, or networks under the control or responsibility of Review Wave through hacking, cracking, password mining, or any other unauthorized means.

Review Wave is not a party to any Document executed via the Services.


Review Wave has no control over the contents of any Document.  Review Wave makes no representation or warranty regarding any transaction sought to be effected by any Document.


Review Wave is not responsible or liable to determine whether any particular Document is subject to an exception to applicable electronic signature laws, or whether it is subject to any particular agency promulgations, or whether it can be legally formed by electronic signatures.


Review Wave is not responsible for determining how long any contracts, documents, and other records are required to be retained or stored under any applicable laws, regulations, or legal or administrative agency processes. Further, Review Wave is not responsible for or liable to produce any of your Documents or other documents to any third parties.


With respect to "consumers", as that term is defined under applicable consumer protection laws imposing the requirement that parties to an electronic contract consent to the method of contracting (among other requirements), Review Wave does not and is not responsible to: i.) determine whether any particular transaction involves a consumer; ii.) furnish or obtain any required consents or determine if any such consents have been withdrawn with respect to the contracting method; iii.) provide any information or disclosures in connection with any attempt to obtain any such consents; iv.) provide legal review of, or update or correct any information or disclosures currently or previously given; v.) provide any such copies or access, except as expressly provided in the Documentation for all transactions, consumer or otherwise; or vi.) comply with any such requirements.  You shall be responsible for determining if any contracting party is a consumer, and if so, to comply with all requirements imposed by law as a result thereof.


You agree that you are solely responsible for the accuracy and appropriateness of instructions given by you and your personnel in relation to the Services.


You warrant that you have the requisite authority to provide Review Wave with, and to accept from Review Wave, any required authorizations, requests, or consents, on behalf of you, your entity, and/or the entity you represent.

  1. TERM AND TERMINATION.
    • Term of Agreement. These Terms shall be effective from the moment you first access the Service until your use of the Service has completely ceased.  Review Wave may terminate or suspend your use of the Services and deny you access to its website in its sole discretion for any reason or no reason.  Review Wave may notify you prior to any such termination or suspension at its discretion.
    • Survival Provisions. The rights and obligations of the Parties under Sections 1.3, 2.1 - 2.4, 3, 4.2, 5 and 7 shall survive the expiration or termination of these Terms.
  1. INDEMNIFICATION.
    • Indemnity. You agree to release, defend, indemnify, and hold Review Wave, affiliates, and subsidiaries, and their officers, directors, employees, and agents, harmless from and against any claims, liabilities, damages, losses, and expenses, including, without limitation, reasonable legal and accounting fees, arising out of or in any way connected with your access to or use of the Service, or your violation of any term or warranty contained within these Terms.
  1. DOCUMENT RETENTION AND DATA PROTECTION.
    • Document Retention. Review Wave may store documents sent for signature via the Services ("Documents") when it is commercially reasonable to do so.  Review Wave may, at its sole discretion, delete incomplete Documents from the Services systems.
    • Transaction Data Retention. Review Wave may retain Transaction Data for as long as it has a business purpose to do so.

"Transaction Data" means metadata associated with a Document, such as transaction history, image hash value, method and time of Document deletion, sender and recipient names, e-mail addresses, signature IDs, and other unique identifiers and time/date stamps.

  • Protection of Data. You acknowledge that Review Wave has no obligation to protect your data that is stored or transmitted outside of the Services.  Review Wave will employ commercially reasonable measures to protect your data from unlawful or unauthorized access, use, alternation, or disclosure during transit and storage within the Services.
  1. GENERAL.
    • Terms. In the event that any one or more of the provisions of these Terms are for any reason held to be illegal or unenforceable in any respect, such illegality or unenforceability shall not affect the other provisions of these Terms, which shall remain in full force and effect.
    • Entire Agreement. This Agreement, the policies incorporated by reference hereto, and the agreements covering the individual services offered pursuant to the terms herein reflect the entire agreement between the parties with respect to the matters therein, and supersede all proposals, prior agreements, and commitments, whether oral or written, and all negotiations, conversations, or discussions between the Parties relating thereto.
    • Modifications. These Terms may be modified from time to time by Review Wave at its sole discretion.  Your use of the Service signifies your agreement to these changes.  You will be notified of material changes by notice on the website or via e-mail.
    • Assignment. You may not assign or delegate the rights and obligations of these Terms without the prior express written permission of Review Wave.  Review Wave may unilaterally assign or delegate the rights and obligations of these Terms at its sole discretion.  These Terms shall be binding upon and inure to the benefit of the Parties and their successors and permitted assigns.
    • Litigation of Intellectual Property. Notwithstanding the parties' decision to resolve all disputes through arbitration, either party may bring enforcement actions, validity determinations, or claims arising from or relating to theft, piracy, or unauthorized use of intellectual property in any state or federal court with jurisdiction or in the U.S. Patent and Trademark Office to protect its intellectual property rights ("intellectual property rights" means patents, copyrights, moral rights, trademarks, and trade secrets, but not privacy or publicity rights) .

 

  • Contact Information. If you have any questions, concerns, or complaints about our Services or anything under these Terms or other agreements with us, please contact us at the following email address.

Email:  support (at) reviewwave.com


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Office Hours

Our 96th Street office is convenient to north Indianapolis, Nora, Carmel, and Zionsville.

Chiropractic Office Hours - Dr. Mary Jo Johnson

Monday:

10:30 am-5:30 pm

Tuesday:

9:00 am-4:00 pm

Wednesday:

10:30 am-5:30 pm

Thursday:

9:00 am-4:00 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Chiropractic Office Hours- Dr. Steve Avitabile

Monday:

7:00 am-9:00 am

Tuesday:

7:00 am-9:00 am

Wednesday:

7:00 am-9:00 am

Thursday:

7:00 am-9:00 am

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Therapeutic Massage - Becky Troyer, CMT

Monday:

10:00 am-7:00 pm

Tuesday:

10:50 am-7:30 pm

Wednesday:

10:00 am-7:00 pm

Thursday:

Closed

Friday:

Special appointment only.

Saturday:

Closed

Sunday:

Closed

Therapeutic Massage-Sheryl Lanham, CMT

Monday:

9:40 am-6:40 pm

Tuesday:

9:40 am-6:40 pm

Wednesday:

9:40 am-6:40 pm

Thursday:

9:40 am-6:40 pm

Friday:

Closed

Saturday:

Closed

Sunday:

Closed

Therapeutic Massage- Kriss Luckett-Ziesemer, CMT

Monday:

Closed

Tuesday:

Closed

Wednesday:

Closed

Thursday:

9:20 am-5:40 pm

Friday:

10:00 am-12:30 pm

Saturday:

Closed

Sunday:

Closed

Therapeutic Exercise- Savannah Fisher, MSK

Monday:

10:30 am-5:30 pm

Tuesday:

9:00 pm-4:00 pm

Wednesday:

10:30 am-5:30 pm

Thursday:

9:00 am-4:00 pm

Friday:

9:00 am-3:00 pm

Saturday:

Closed

Sunday:

Closed

Location

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Testimonials

Reviews By Our Satisfied Patients

  • "Dr. Johnson is an amazing chiropractor and an amazing woman. Her staff is great, everyone is kind and there to be of service. Dr. Johnson will help you get your whole wellness life together, and will do it with kindness and care. I would send anyone here."
    Mr. K.
  • "Fantastic people doing great work in this office. I have had back pain since my mid-20's. The chiropractic work helped, but then Kurt was able to help me figure out I had a wheat intolerance that was the root cause of my problems. If you are looking for a great support system for your health needs, look no further!"
    Jeff C.
  • "I love this place!!!  I had never been to a Chiropractor before, i thought they were scary, with all the old school treatment.  Dr. Johnson is the best, her treatment plan has worked for me, i was a mess when i first went there, i suffered for months with the pain in neck, upper back and shoulders, starting the treatment on 5/25/2019.  i am so much better now!Her staff is also friendly and kind, and very knowledgeable, her front desk receptionist, Emily, is the best also!  Thank you all so much!"
    Kim K.
  • "Thank you Dr. Johnson - your gentle and holistic approach to chiropractic care and wellness is greatly appreciated. Your work and that of your wellness team is among the best!"
    R.D. Indianapolis /Indianapolis, IN