West Henrietta (585) 444-0340

West Henrietta (585) 444-0340

New Patient forms Lima


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. 

About this Patient 

Marital Status
Is this visit related to a MVA?

Initial Consultation Form

What is your type of complaint?*
Please select at least one option
How did this injury occur?*
Please select one option
How often does the frequency of symptoms occur?*
Please select one option
What is the quality of your discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to?*
Please select at least one option
How have the symptoms changed since they started?*
Please select one option
On a scale from 1-10, with 10 being the worst pain, what would you rate your pain?*
Please select one option
Are your symptoms relieved by any of the following? Check all that apply*
Please select at least one option
What aggravates the symptoms? Check all that apply*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has you received any past care for this complaint?*
Please select at least one option
Have any diagnostic images or tests (ex. X-ray/MRI) been performed?*
Please select one option
What activities of daily living are affected?*
Please select at least one option
What are your specific therapeutic goals?*
Please select at least one option
Have you ever been to a Chiropractor before?*
Please select one option

Review of Systems

Please mark the areas that describe your health history:*
Please select at least one option
FEMALE ONLY: Are you pregnant?
Past history of accidents or trauma?*
Please select at least one option
Do you smoke?*
Please select one option
Have you/do you drink alcohol?*
Please select one option

Patient Privacy Questionnaire

Please list the names of any family/significant other whom we may inform about your medical condition and your diagnosis. (treatment, payment and health care operations) and in case of emergency.

Patients Affirmation of Receipt of Patient's Statement of Privacy Rights

I hereby acknowledge receipt of this office's Statement of Privacy Rights, provided on my behalf and in accordance with law, and have read and understand my rights to privacy and security of Personal Health Information, as a patient of this practice.

Informed consent of care/examination

Chiropractic care or massage, like all forms of health care, while offering benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/ strain injuries , irritation of a disc condition, and rarely fractures. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be vertebral artery injury that could lead to stroke.

Prior to receiving chiropractic care at this chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your are or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care.

I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment.

I, being parent/legal guardian (named below) of patient (listed below), do hereby grant permission for him/her to receive care from a doctor at Family Chiropractic Center for Wellness, Inc. This shall include when necessary standard analysis, including x-rays and corrective spinal adjustments

Assignment of Benefits

I, hereby authorize (party named below) to make medical benefits payments otherwise payable to me for the services rendered at Crossroads Chiropractic and Health Center, P.C., but not to exceed the charges of those services, payable to and mailed directly to: Crossroads Chiropractic and Health Center P.C. 1879 Rochester St. Lima, NY 14485. Furthermore, I hereby IRREVOCABLY ASSIGN to Crossroads Chiropractic and Health Center, P.C. the rights and benefits under any policy of insurance, Indemnity agreement, or any other collateral source as defined in New York Statutes for any services and or charges provided by Crossroads Chiropractic and Health Center, P.C. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other insurance is indicated in Item 9 of the CMS-1500 claim form. or elsewhere on the approved claim form of electronically submitted claims, my signature authorizes releasing the information to the insurer or agency listed. Crossroads Chiropractic and Health Center, P.C. agrees to accept the charge determined by the insurance company as the full charge. The patient is responsible only for the deductible, coinsurance, and non-covered items. Coinsurance and deductible are based upon the charge determination to the insurance carrier.


Cancellation Policy


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our reception. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a $25.00 fee.
  • 24 hours notice is required when cancelling a appointment as this allows the opportunity for someone else to schedule an appointment. If you fail to notify us in a timely manner you will be charged $25.00. The fee must be paid prior to your next scheduled appointment.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Medical Release


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.


Patient Financial Responsibility Policy 

In order for Crossroads Chiropractic to continue providing our patients with quality chiropractic care, we must receive payment for our services. Ensuring that we are appropriately and promptly paid is the patient's responsibility.

As a patient at Crossroads Chiropractic, you agree and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. It is common for insurances to not cover therapy services; therefore, the patient will be responsible for the charge at the time of service.

In the event that your insurance is not valid or your coverage was terminated at the time the services are rendered, you will be solely responsible for the full amount of your office visit and/or any procedures rendered. Private pay fees are $50 per visit and an additional $25-$75 for elective therapies received.

I understand and agree to be responsible for the payment of all unpaid services rendered on my behalf or my dependents, including a 35% fee should collection service be needed. I understand, agree, and authorize that if my account remains unpaid and is turned over to a third-party agency, that agency may contact me regarding my account(s) and any other account(s) for which I am a responsible guarantor, or to recover any unpaid portion of my obligation to Crossroads Chiropractic through an automated or predictive dialing system, pre recorded messaging system, or texting platform at the phone number (including any cell phone number), or via my email address as provided.

Our experience has shown that it is wise to have an understanding with our clients as to our office policies and fees. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and will do our best to help you.

I understand and agree to all the information written above.

AUTHORIZATION FOR RELEASE OF INFORMATION

I HEREBY AUTHORIZE RELEASE OF MY PROTECTED HEALTH CARE OR RELATED INFORMATION AS DESCRIBED BELOW

Persons/Organization Receiving and Providing the Information: Crossroads Chiropractic and Health Center, P.C. 

Dr. Joseph D. Donnelli, Dr. Christopher Swanson and Dr. Meghan Villnave


Specific description of information to be disclosed:

Treatment plan to primary care doctor as needed

Medical records

X-rays and/or report of findings, CT Scans, MRIs

Consult reports from specialists

Test results

Billing records

Other ________________________________________________________

By signing this form I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The revocation will only be effective from the date the written revocation is provided and will not apply retroactively.

The practice has the right to restrict the use of information but the practice does not have the right to agree to those restrictions.

The practice reserves the right to change the privacy policy as allowed by law.

The practice may condition receipt of treatment upon execution of this consent.





Your signature below will acknowledge and understand this and the policies outlined above.

Thank you for taking the time to fill 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. 

About this Patient 

Marital Status
Is this visit related to a MVA?

Initial Consultation Form

What is your type of complaint?*
Please select at least one option
How did this injury occur?*
Please select one option
How often does the frequency of symptoms occur?*
Please select one option
What is the quality of your discomfort?*
Please select at least one option
If the discomfort radiates, where does it travel to?*
Please select at least one option
How have the symptoms changed since they started?*
Please select one option
On a scale from 1-10, with 10 being the worst pain, what would you rate your pain?*
Please select one option
Are your symptoms relieved by any of the following? Check all that apply*
Please select at least one option
What aggravates the symptoms? Check all that apply*
Please select at least one option
Any past episodes of this complaint?*
Please select one option
Has you received any past care for this complaint?*
Please select at least one option
Have any diagnostic images or tests (ex. X-ray/MRI) been performed?*
Please select one option
What activities of daily living are affected?*
Please select at least one option
What are your specific therapeutic goals?*
Please select at least one option
Have you ever been to a Chiropractor before?*
Please select one option

Review of Systems

Please mark the areas that describe your health history:*
Please select at least one option
FEMALE ONLY: Are you pregnant?
Past history of accidents or trauma?*
Please select at least one option
Do you smoke?*
Please select one option
Have you/do you drink alcohol?*
Please select one option

Patient Privacy Questionnaire

Please list the names of any family/significant other whom we may inform about your medical condition and your diagnosis. (treatment, payment and health care operations) and in case of emergency.

Patients Affirmation of Receipt of Patient's Statement of Privacy Rights

I hereby acknowledge receipt of this office's Statement of Privacy Rights, provided on my behalf and in accordance with law, and have read and understand my rights to privacy and security of Personal Health Information, as a patient of this practice.

Informed consent of care/examination

Chiropractic care or massage, like all forms of health care, while offering benefit may also provide some level of risk. This level of risk is most often very minimal, yet in rare cases injury has been associated with chiropractic care. The types of complications that have been reported secondary to chiropractic care include sprain/ strain injuries , irritation of a disc condition, and rarely fractures. One of the rarest complications associated with chiropractic care, occurring at a rate between one instance per one million to one per two million cervical spine (neck) adjustments may be vertebral artery injury that could lead to stroke.

Prior to receiving chiropractic care at this chiropractic office, a health history and physical examination will be completed. These procedures are performed to assess your specific condition, your overall health and, in further examinations or studies are needed. In addition, they will help us determine if there is any reason to modify your are or provide you with a referral to another health care provider. All relevant findings will be reported to you along with a care plan prior to beginning care.

I understand and accept that there are risks associated with chiropractic care and give my consent to the examinations that the doctor deems necessary, and to the chiropractic care including spinal adjustments, as reported following my assessment.

I, being parent/legal guardian (named below) of patient (listed below), do hereby grant permission for him/her to receive care from a doctor at Family Chiropractic Center for Wellness, Inc. This shall include when necessary standard analysis, including x-rays and corrective spinal adjustments

Assignment of Benefits

I, hereby authorize (party named below) to make medical benefits payments otherwise payable to me for the services rendered at Crossroads Chiropractic and Health Center, P.C., but not to exceed the charges of those services, payable to and mailed directly to: Crossroads Chiropractic and Health Center P.C. 1879 Rochester St. Lima, NY 14485. Furthermore, I hereby IRREVOCABLY ASSIGN to Crossroads Chiropractic and Health Center, P.C. the rights and benefits under any policy of insurance, Indemnity agreement, or any other collateral source as defined in New York Statutes for any services and or charges provided by Crossroads Chiropractic and Health Center, P.C. I understand that my signature requests that payment be made and authorizes release of medical information necessary to pay the claim. If other insurance is indicated in Item 9 of the CMS-1500 claim form. or elsewhere on the approved claim form of electronically submitted claims, my signature authorizes releasing the information to the insurer or agency listed. Crossroads Chiropractic and Health Center, P.C. agrees to accept the charge determined by the insurance company as the full charge. The patient is responsible only for the deductible, coinsurance, and non-covered items. Coinsurance and deductible are based upon the charge determination to the insurance carrier.


Cancellation Policy


We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards are provided to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our reception. We would prefer the make up appointment to be within the same week.
  • In the instance of a no show without notice by phone we reserve the right to charge you a $25.00 fee.
  • 24 hours notice is required when cancelling a appointment as this allows the opportunity for someone else to schedule an appointment. If you fail to notify us in a timely manner you will be charged $25.00. The fee must be paid prior to your next scheduled appointment.


Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Medical Release


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.


Patient Financial Responsibility Policy 

In order for Crossroads Chiropractic to continue providing our patients with quality chiropractic care, we must receive payment for our services. Ensuring that we are appropriately and promptly paid is the patient's responsibility.

As a patient at Crossroads Chiropractic, you agree and understand your insurance plan benefits and your responsibility for any deductibles, co-insurance, or co-payment amounts prior to any visit. Not all services are covered in all insurance contracts. If your insurance plan does not cover a service or procedure, you are responsible for payment of these charges. It is common for insurances to not cover therapy services; therefore, the patient will be responsible for the charge at the time of service.

In the event that your insurance is not valid or your coverage was terminated at the time the services are rendered, you will be solely responsible for the full amount of your office visit and/or any procedures rendered. Private pay fees are $50 per visit and an additional $25-$75 for elective therapies received.

I understand and agree to be responsible for the payment of all unpaid services rendered on my behalf or my dependents, including a 35% fee should collection service be needed. I understand, agree, and authorize that if my account remains unpaid and is turned over to a third-party agency, that agency may contact me regarding my account(s) and any other account(s) for which I am a responsible guarantor, or to recover any unpaid portion of my obligation to Crossroads Chiropractic through an automated or predictive dialing system, pre recorded messaging system, or texting platform at the phone number (including any cell phone number), or via my email address as provided.

Our experience has shown that it is wise to have an understanding with our clients as to our office policies and fees. Therefore, this form has been prepared for your convenience and information. We offer several methods of payment for your care at our office and you may choose the plan that you prefer. This information will enable us to better serve you and help to avoid misunderstandings in the future. Our main concern is your health and well being and will do our best to help you.

I understand and agree to all the information written above.

AUTHORIZATION FOR RELEASE OF INFORMATION

I HEREBY AUTHORIZE RELEASE OF MY PROTECTED HEALTH CARE OR RELATED INFORMATION AS DESCRIBED BELOW

Persons/Organization Receiving and Providing the Information: Crossroads Chiropractic and Health Center, P.C. 

Dr. Joseph D. Donnelli, Dr. Christopher Swanson and Dr. Meghan Villnave


Specific description of information to be disclosed:

Treatment plan to primary care doctor as needed

Medical records

X-rays and/or report of findings, CT Scans, MRIs

Consult reports from specialists

Test results

Billing records

Other ________________________________________________________

By signing this form I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The revocation will only be effective from the date the written revocation is provided and will not apply retroactively.

The practice has the right to restrict the use of information but the practice does not have the right to agree to those restrictions.

The practice reserves the right to change the privacy policy as allowed by law.

The practice may condition receipt of treatment upon execution of this consent.





Your signature below will acknowledge and understand this and the policies outlined above.

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

Location

Office Hours

Crossroads Chiropractic Lima

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

1:00 pm - 5:00 pm

Wednesday

8:00 am - 12:30 pm

2:00 pm - 5:00 pm

Thursday

1:00 pm - 6:00 pm

Friday

8:00 am - 11:30 am

1:00 pm - 5:00 pm

Saturday

*Select Saturdays

Sunday

Closed

Crossroads Chiropractic West Henrietta

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

1:00 pm - 6:00 pm

Wednesday

8:00 am - 4:00 pm

Thursday

1:00 pm - 6:00 pm

Friday

8:00 am - 12:30 pm

Saturday

Closed

Sunday

Closed

Crossroads Chiropractic Lima

Monday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
1:00 pm - 5:00 pm
Wednesday
8:00 am - 12:30 pm 2:00 pm - 5:00 pm
Thursday
1:00 pm - 6:00 pm
Friday
8:00 am - 11:30 am 1:00 pm - 5:00 pm
Saturday
*Select Saturdays
Sunday
Closed

Crossroads Chiropractic West Henrietta

Monday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
1:00 pm - 6:00 pm
Wednesday
8:00 am - 4:00 pm
Thursday
1:00 pm - 6:00 pm
Friday
8:00 am - 12:30 pm
Saturday
Closed
Sunday
Closed