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

About the Spouse 

Employer Information

Initial Consultation Form 


Reason for this Visit

Is the purpose of this appointment related to:*
Please select one option
Overall frequency of complaint ( choose one)
Overall intensity of complaint (choose one)
If yes, please select the amount below that you feel your symptoms increase at work:

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Experience with Chiropractic 

Goals for my Care

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program.

Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Habits & Conditions

Medications I Now Take:
Do you exercise regularly?*
Please select one option
Do you wear:
Health Conditions:

FOR WOMEN ONLY:

Emergency Contact

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

Nutrition and self-care are just two of the components in obtaining optimal wellness. 


Please let us know what you are currently doing for your health.

Things I do currently to support my health include:
Please indicate which of these you do/have on a consistent basis:

Missed Appointments 


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, there will be a $50 fee for any appointments not canceled at least 24 hours prior to the 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.

Finical Responsibility Statement:


I understand and agree that insurance policies are an arrangement between me and an insurance carrier. Furthermore, I understand that Chiropractic Center for Families will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to Chiropractic Center for Families will be credited to my account upon receipt. However, I clearly understand and agree that all services rendered to me are charged directly and that I am personally responsible for payment. Any account not paid within 90 days will be subject to collections. I also understand that if I suspend or terminate my care and treatment, against the doctor's recommendation, my account balance will be immediately due and payable. Medicare patients are responsible for their co-insurance, deductible, and any items deemed Medically Unnecessary by Medicare. If you have insurance that covers your co-insurance and deductible, we will file on your behalf. Any patient 18 years or older will be financially responsible for all charges incurred. A $30 Returned Check Fee will be assessed to your account for every check returned to Chiropractic Center for Families as non-payable. With the exception of emergency situations, you will be held financially responsible for any scheduled appointment not canceled at least 24 hours prior to the appointment. In the event of default payment, the undersigned agrees to pay all costs of collection of delinquent amounts, including court costs, and reasonable attorney fees. 

Records Release:

I hereby authorize Chiropractic Center for Families to release my medical records or copies of such necessary to process this claim. 

Acknowledgment Of Receipt Of Notice of Privacy Practices:

I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

  • The right to review the notice prior to signing this consent 
  • The right to object to the use of my health information for directory purposes 
  • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations

Informed Consent To Chiropractic Treatment and/or Therapeutic Massage Therapy 

The nature of Chiropractic/ massage treatment: The doctor will use his/her hands and/or mechanical device to move your joints and/or muscles. You may feel a "click" or a "pop" noise when a knuckle is "cracked," and you may feel movement of the joint and/or muscle. Various ancillary procedures, such as hot or cold packs, electric muscle stimulation, therapeutic ultrasound, and/or dry hydrotherapy may also be used. Possible risks: As with any healthcare procedures, complications are possible following any type of manipulation. Complications could include bone fractures, muscle strain, ligament strain, joint dislocation, or injury to intervertebral discs, nerves, or spinal cord. Cerebrovascular injury or stroke could occur upon severe injuries to arteries or neck. A minority of patients may notice stiffness or soreness after the first few days of treatment. he ancillary procedures could produce skin irritations, burns, or minor complications. Probability of Risks Occurring:  The risks of complications due to treatment have been described as "rare", about as often as complications seen from taking a single aspirin. The risk of cerebrovascular injury or stroke has been estimated as one in one million to one in twenty million and can be even further reduced by screening procedures. The probability of adverse reaction due to ancillary procedures is also considered "rare". Other treatment options to consider: Over-the-counter analgesics; the risks of these medications include irritation to the stomach, liver and kidneys, and other side effects in a significant number of cases. Medical care; typically anti-inflammatory drugs, tranquilizers, and analgesics. Risks of these drugs include a multitude of undesirable side effects and patient dependence in a significant number of cases. Hospitalization; in conjunction with medical care adds risks of adverse reactions to anesthesia, aswell as an extended convalescent period in a significant number of cases. Risks of remaining untreated: Delay of treatment allows formation ofadhesion's, scar tissue and other degenerative changes. These changes can further reduce skeletal mobility, and induce chronic pain cycles. It isquite probable that delay of treatment will complicate the condition and make further rehabilitation more difficult. Unusual risks: I have had thefollowing unusual risk of my case explained to me. I have read the explanation above of chiropractic treatment. I have had the opportunity tohave any questions answered to my satisfactions. I have fully evaluated the risks and benefits of undergoing treatment. I have freely decided toundergo the recommended treatment, and hereby give my full consent to treatment.

I have read and agree to the above statements.

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

Locations

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Office Hours

CALL or TEXT for an appointment (843) 236-9810

Dr. Tori Ritchie, DC and Dr. Sandra Buffkin, DC

Monday

9:00 am - 1:00 pm

Tuesday

1:00 pm - 6:00 pm

Wednesday

9:00 am - 1:00 pm

3:00 pm - 4:00 pm

Thursday

9:00 am - 1:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 1:00 pm

Saturday

Closed

Sunday

Closed

Dr. Tori Ritchie, DC and Dr. Sandra Buffkin, DC

Monday
9:00 am - 1:00 pm
Tuesday
1:00 pm - 6:00 pm
Wednesday
9:00 am - 1:00 pm 3:00 pm - 4:00 pm
Thursday
9:00 am - 1:00 pm 2:00 pm - 6:00 pm
Friday
9:00 am - 1:00 pm
Saturday
Closed
Sunday
Closed