Online Forms

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. 


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. 

Employer Information

Emergency Contact

Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option
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:

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.



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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

Find us on the map

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