113 N 2nd Ave
St. Charles, IL 60174
630-762-9864

Patient Forms | Tranquility Spa & Wellness Center

Patient Forms | Tranquility Spa & Wellness Center

New Patient Forms

Acupuncture Forms for Dr. Susan Sterling
Chiropractic Medicine Forms for Dr. Emily Loveland and Dr. Kalli Prater
Natural Medicine Forms for Dr. Kalli Prater

*In an effort to reduce paper usage, Tranquility Wellness has implemented an Electronic Medical Records system. New patients for Dr. Emily Loveland and Dr. Kalli Prater should arrive 15-20 minutes prior to your scheduled appointment time to complete the electronic forms. Thank you.

Additional Forms for Tranquility Wellness Chiropractic & Natural Medicine

Insurance Coverage Worksheet
Medical Records Release Form
HIPPA

Tranquility Wellness’ Policies & Payments

Please arrive 15 minutes prior to all appointments.  New patients may want to allow more time to fill out paperwork.  Forms are available on the website to download and fill out at your convenience.  Please fill out the appropriate forms and bring them to your first appointment.

Prior Laboratory, X-ray or MRI/CT reports may be beneficial for your health care practitioner to diagnose appropriately.  If possible please fax (630.762.1480), mail or drop off this information for review before your appointment.

If you would like Tranquility Wellness to bill to your health insurance company, please bring your insurance card and driver’s license to your first visit for us to copy.  Tranquility Wellness will submit on your behalf to any in-network or out-of-network health insurance company (excluding HMOs).  Payments for maintenance/wellness care or non-covered services are expected in full at the time of service.

As a patient, you will be responsible for any co-pay, deductible, co-insurance, non-covered or denied charges.  Please contact your insurance company’s benefits department for your exact policy coverage.

Tranquility Wellness offers quality and affordable health care for both insurance covered patients and cash patients.  A copy of the Tranquility Wellness Fee Schedule is available upon request at the front desk.  Cash payments are due in full at the time of service.

To avoid a missed appointment fee of $25.00, kindly give at least 24-hour notice if you need to reschedule or cancel an appointment.

For additional questions, please email drloveland@relaxattranquility.com.
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