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Welcome

At Fern Creek Chiropractic Center, we've been helping Louisville families achieve optimal wellness since 1997 through our unique blend of traditional chiropractic care and functional health approaches.

 

We're delighted that you've chosen us as your partner in health and are committed to making your experience exceptional from the start.

 

We look forward to meeting you and supporting your family's wellness journey!

What to do...
1. Complete Health Record
2. Complete Intake form
3. Schedule appointment

Who Should Fill Out New Patient Paperwork?
(never been to our office or its been > 3 years)

Click on only 1 of these bubbles to complete your
CONFIDENTIAL HEALTH RECORD

Step 1

Step 2

You will be redirected to our Intake Form when you complete your Paperwork below. If you do not, you may click on this link to go there. You may schedule your appointment here also.

Complete Your Paperwork Here

If paperwork will NOT submit, you have not completed all the REQUIRED fields

ALL NEW PATIENTS COMPLETE THIS FORM

Confidential New Patient Health Record

Welcome to Fern Creek Chiropractic Center. Please take a few moments to complete this form to the best of your ability. The information provided in this form will help us achieve the best possible outcome. Note that information collected via this form is private and protected from disclosure by applicable law.


IMPORTANT: If this appointment is due to a CAR ACCIDENT, you will need to also complete the Auto Insurance & Car Accident Report form.


All fields with a * are required. The form will NOT submit if any are blank.

Personal Information

Birthday
Día
Mes
Año
Height (foot)
Height (inches)
Identify as...
Are you currently pregnant?
Yes
No
Unsure
How did you hear about our office?
Have you been to a chiropractor before?
Yes
No
What techniques were used by your previous chiropractor?

Employment Information

Employment Status

Health Insurance Information

**PLEASE NOTE: We will verify benefits and file your insurance as a courtesy to you. If your insurance company does not cover all of your services, you are responsible for payment. We will provide you with this information to the best of our ability. However, it is YOUR responsibility to know your coverage, eligibility, and, if you need a referral, to obtain this prior to your visit. YOU are ultimately responsible for your bill.

Who ELSE is responsible for your bill?
Health Insurance Carrier
Who is primary on your insurance?
Primary's Date of Birth
Día
Mes
Año

***IMPORTANT: If this is an AUTO ACCIDENT, you will give us the Auto Insurance information on the Motor Vehicle Accident Form.

Records Access & Release

I authorize the following person to have access to and to use or disclose the protected health information in my file at Fern Creek Chiropractic Center.

Primary Health or Injury Concern

Select
New Condition
New Injury
Exacerbation
Select area
Select side
How did this start?
Have you had a similar injury?
How often are you feeling this?
Select up to 6:
If pain radiates down an arm or a leg where to and how far?
Which side does it radiate to?
What makes it worse?
What makes it better?
When did this start?
When is it worst?
This condition is...

Secondary Health or Injury Concern

Select
New Condition
New Injury
Exacerbation
Select area
Select side
How did this start?
Have you had a similar injury?
How often are you feeling this?
Select up to 6:
If pain radiates down an arm or a leg where to and how far?
Which side does it radiate to?
What makes it worse?
What makes it better?
When did this start?
When is it worst?
This condition is...

Additional Health or Injury Concern

Select
New Condition
New Injury
Exacerbation
Select area
Select side
How did this start?
Have you had a similar injury?
How often are you feeling this?
Select up to 6:
If pain radiates down an arm or a leg where to and how far?
Which side does it radiate to?
What makes it worse?
What makes it better?
When did this start?
When is it worst?
This condition is...

IF AUTO ACCIDENT, ALSO COMPLETE THIS FORM

Auto Insurance & Accident Report

Please take a few moments to complete this form to the best of your ability. Information provided in this form will help us provide the best outcome possible. Note that information collected via this form is private and protected from disclosure by applicable law.

Your Auto Insurance Information

**PLEASE NOTE: Kentucky is a "no-fault" state, which means your medical claims run through YOUR insurance company after you meet your deductible. It is YOUR responsibility to know your deductible. YOU are responsible for your deductible and ultimately responsible for your bill.

NOTE: All fields with an * are required. The form will NOT submit if any are blank.

Who ELSE is responsible for your bill?
Policy Holder's Birthday
Día
Mes
Año

Be advised that we cannot file to your health insurance unless there is no other responsible party or your benefits are exhausted. There are many services covered under auto insurance that are not covered benefits for health insurance. You are responsible for these services. If we do not accept your insurance or if your insurance does not cover all services, you are responsible for payment.

Other Person's Auto Insurance Information

Motor Vehicle Accident Report

Date and Time of Accident
Día
Mes
Año
Horario
HorasMinutos
Location in vehicle
Vehicle size
Vehicle type
Vehicle type
Travel direction
Road conditions
Time of day
Seatbelt
Shoulderbelt
Headrest
Airbags
Was the driver braking at the time of impact?
Did you anticipate the accident?
Vehicle struck
Not reported/unknown
Another vehicle
By another vehicle
A stationary object
Multiple impacts
Collision location
Did your body strike anything in the vehicle?
Areas injured in the accident
At the moment of impact
How did you exit the vehicle?
Not reported/unknown
Under own power
Assisted by EMS
Assisted by others
Was extricated
Were you ejected from the vehicle?
Your Consciousness
Were you Disoriented?
Medical Attention
After the Accident, you went:
Not reported
This office
Urgent Care
Hospital ER
Personal doctor
Home
Work
Resumed activities
Other vehicle size
Not reported/unknown
Subcompact
Compact
Mid-size
Full size
No other vehicle
Other vehicle type
Not reported/unknown
Car
SUV
Truck
Motorcycle
No other vehicle
Other vehicle travel direction
What part of their car hit your car?
Not reported/Unknown
Head on
Front
Behind
Passenger side
Driver side
No other vehicle

Diagnostic Screen for TBI

Have you experienced any of these symptoms continuing after the accident?
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After you submit this form, you will be directed to the Intake Form. This will set up your account in our system and take you to SCHEDULING.

What To Expect On Your First Visit

The initial visit, or New Patient Exam, typically consists of the following:​

​

  • Consultation

  • Initial Exam,

  • Neck and Low Back X-rays (if necessary)

  • Review of X-rays

  • Chiropractic Adjustment

  • Therapy (either Electrical Muscle Stimulation, Cold Laser, and/or Dry Needling).

 

This generally can be done in an hour, however, we do ask that you plan for an hour and a half to complete this visit depending on the detail of exams and review of your health history.

Therapy Paperwork
(If you are planning on utilizing any of these therapies, go ahead and fill these out)

Insurance

Insurance we accept:

Anthem or BC/BS (most), Aetna, All car insurance, Medicare ***MEDICARE: We are Non-Participating Providers. This means: We will file for you. You will pay us directly. ​Medicare will reimburse you (for services they deem medically necessary) 

 

Insurance we do NOT accept:

United, Cigna, Medicaid (any), Humana, Passport, Anthem Medicare, Work Compensation​

Will Insurance Cover Everything?

​The short answer is "no". Depending on the insurance plan you chose, you may have a deductible, copay, or coinsurance.
​
We also offer services that your health insurance does not cover. These items, if selected for your treatment plan, are eligible for our time-of-service discounts.
​
If you are filing with your car accident PIP insurance, most things are covered after you pay your deductible. However, some companies are denying some services.

Self Pay

No insurance, no problem!

If you are self-pay, we offer discounts for payment at the time-of-service. We, also, offer many of our services as packages to save you even more!

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