To save time at your visit, please complete your paperwork ahead of time
Step 1- FORMS: If you have access to a printer, click the link below and print the forms. Please bring these completed forms with you to your scheduled appointment, along with your photo ID and Insurance card. (If you do not have access to a printer, you will be given these forms to complete upon arrival)
Step 2- OPTIONAL: If you have any medical records or radiology reports from another medical provider you would like us to have on file, please print and complete the form below. (You may fax or email this form asap so we can start obtaining your records prior to your visit)
Click to Print Medical Release Form (Optional)
Fax: (336) 996-9878 Email: kcc@kernersvillechiropractic.com
Online Good Faith Estimate / Effective January 1, 2024
NON-INSURANCE RATES
We offer a fee schedule price reduction for billed charges to patients that do not have insurance or are not needing medically necessary chiropractic treatment that would be covered by insurance companies. Almost all insurance companies do not cover maintenance chiropractic care following the initial treatment program. The following are our fee schedule price reductions for billed amounts for these services.
Consulation Only: $25 No exam, therapy or spinal manipulation (No charge if in addition to treatment)
New Patient Exam: $50 New patients and/or more than 3 years since last visit for established patients (required prior to treatment)
Existing Patient Exam: $25 More than 2 years, but less than 3 since last visit… or you receive a new injury that requires new interventions (required prior to treatment)
Wellness Adjustment Under 65: $56 Visit
Wellness Adjustment Over 65, Medicare, Medicaid, Disabled Veteran: $46 Visit
Wellness adjustments are if you have no symptoms OR you have reached the end of a treatment plan and therapeutic benefit
Pre-paid Packages: Wellness visits or elections not to file insurance. (Can be shared with multiple people) **Package prices do not include examination fees
3 Visits: $153 ($15 savings)
10 Visits: $490 ($70 savings)
12 Visits: $576 ($96 savings)
(Pre-paid packages for 65yrs+, Medicare or Medicaid may be purchased at $46/visit for any quantity of visits)
Graston Technique: $35 A specialized treatment performed for certain conditions
Kinesio Taping: $11 Applying Kinesio tape for therapeutic benefit (No charge if you bring in your own tape)
Office Visit: $46 Therapy & consult only, no spinal manipulation or examination
