A Warm Welcome to you! Thank you for coming to our practice. 

Doctors of Chiropractic have extensive educational backgrounds, which include a Bachelor of Science, 

Biochemistry, Nutrition, as many Pathology hours as an M.D. and a year in the Cadaver lab. There are 

National and State Board exams which must be passed. 

D.Cs are licensed by the State of California to advise on the health of the spine and nervous system as 

well as nutrition and supplements, exercise, and natural health. 

Dr. Sheehan has been an I.C.U. nurse with babies and children for 15 years, bringing her knowledge of 

Allopathic Medicine to your care. In addition to this, Dr. Sheehan underwent 8 additional years of 

training in the C1 vertebrae and neurology surrounding the brainstem to become certified as an Atlas 

Orthogonalist. 

You will get much more out of your care if you agree to follow care recommendations. These are based 

upon scoring your level of pain with the findings of your exams and x‐rays. These are averaged together 

and help the doctor determine your frequency of care.  

We look forward to giving you care and the wonderful experience of great health! 

 

Dr. Sheehan and staff 

Techniques Practiced By Dr. Sheehan 

Alphabiotics 

Atlas Orthogonal 

Bowen Therapy 

Cranial Nasal Specifics 

Craniosacral Therapy 

Diversified Technique 

Epley Maneuver 

Logan Basic 

Neurolink 

Organ‐Body Point Muscle Testing 

Pelvic Shearing Correction 

Total Body Modification 

Webster Techinque 

Curriculum Vitae  Laura A. Sheehan, R.N., D.C.  Specialty: Upper Cervical Chiropractic Pediatric Chiropractic Pregnancy Chiropractic  Professional Education: Life Chiropractic College West – Doctor of Chiropractic – Hayward, California Dallas Baptist University – Bachelor of Science, major Nursing, Dallas, Texas                Academic excellence in Nursing award  Board Certification: Sherman College of Upper Cervical Chiropractic, BCAO 2011  Research Experience: Yale University Medical School of Epidemiology and Perinatology        EMF effects on Birth weight and Apgars of Neonates       Yale New Haven Hospital NICU‐Indomethicin drug study       Dallas Allergy Clinic‐Bectamethasone drug trial, principle  Other Studies:   Craniosacral Therapy Level I‐III, Upledger Institute       Massage certification, 150 hours, Diamond Light Massage School       Reiki Master, San Francisco 1991       Pediatric Chiropractic Post graduate studies, ICPA       Bowen Therapy Level I‐VI  Publications:    “Upper Cervical Care for Infants and Children”, Pediatric       Chiropractic Textbook, Lippincott, 2011 chptr. 31  Professional     Upper Cervical Chiropractic Association Membership:    International Chiropractic Pediatric Association       California Chiropractic Association 

Important Medical Payments Coverage Make sure you have this coverage on your auto policy. For pennies a day, Medical Payments Coverage pays doctor’s bills, hospital bills and other related costs for you, your family and other passengers in your car, regardless of who is at fault in an accident. We recommend you carry a minimum of $5,000 med pay coverage on your auto policy but for a few dollars more you could have $10,000. (Keep in mind, one day in the hospital can be at least $5,000) We also recommend the following insurance companies who treat their medical payments policy holder with respect at this time: CSAAIB State Farm Insurance We do not recommend the following insurance companies who give their own policy holders a great many problems: Allstate Insurance Farmers Insurance USAA Insurance

Name _________________________________ Date of Birth ____/____/______Age _____ Sex _______ 

Street ________________________________ _______________________________________________ 

City, State, Zip _________________________________________________________________________ 

Occupation _________________________________ Employer _________________________________ 

Home Phone  ___________________________ Work Phone _______________________ Ext. ________ 

Cell Phone ______________________________ Social Security Number _____‐______‐______ 

Email Address _________________________________________________________________________ 

Spouse ______________________________ Referred By ______________________________________ 

What is your major complaint? ___________________________________________________________ 

How long have you had this condition?  __________________ Previously? Date ____________________ 

What aggravates your condition? _________________________________________________________ 

Is this condition getting progressively worse? Y ___ N___ Comes and Goes ________________________ 

Is this interfering with Work___ Sleep ___ Daily Routine ___ Other ______________________________ 

How long has it been since you really felt good? ______________________________________________ 

Other complaints? _____________________________________________________________________ 

Are you taking any medication? ___________________________________________________________ 

Other doctors seen for this condition DC______________ MD_______________ Other_____________

 

Accident 

Happened at Work___ Auto ___ Other ____ 

Date of Accident ____/____/_____ 

Where did injury occur _________________ 

 

Workers Comp 

Employer notified Y___ N ____ 

Have you missed work? Y___ N ___ 

Date last work ____/____/______ 

 

I clearly understand and agree that all services rendered to me are charged directly to me and that I am 

personally responsible for payment. I have been informed in advance and in writing that Dr. Sheehan is 

not a participant in any HMO, Health Organization or network associated with my health insurance. I 

also understand that if I suspend or terminate my care and treatment  fees for professional services 

rendered to me will be immediately due and payable. 

Patient’s Signature ______________________________________________ Date ___/___/___ 

Informed Consent

By signing this form, you are consenting to an examination by Laura Sheehan, D.C. Dr. Sheehan employs standard chiropractic examination including the following:

Observation: General assessment and appraisal in all positions Inspection: Viewing/looking at your body parts/ Visualization includes general viewing in a standard position, front, back and side. All symptomatic (painful) body parts

may be viewed. Women may continue wearing their bra in the course of examination unless it obscures

visualization/viewing of injured/abnormal parts. Women may request a female observer be present at any time.

Auscultation: Using the stethoscope to listen for the blood pressure and other body sounds.

Palpation: This means the doctor will touch you. She will feel for tenderness, heat, swelling, nodularity, laxity of tissues, integrity and abnormality.

Percussion: Using rubber hammer and tapping on bones or tendons. Orthopedic/neurological testing: These are standard tests to access your

neuromusculo-skeletal systems. Notes: You do not have to submit to any examination procedure. Dr. Sheehan would like you to comply to the best of your ability and report changes in your pain. All procedures are accomplished to your tolerance. By signing this form you are consenting to an examination and/or treatment by Dr. Laura Sheehan at 915 Irving St., San Francisco, Ca 94122. Dr. Sheehan employs standard chiropractic methods including: cranial sacral therapy, myofascial release work, intermittent flexion distraction, observation, inspection, auscultation, percussion, palpation, manipulation, ultrasound, sine wave, hot packs, cold packs, traction, x-rays, and recommendation of orthopedic appliances, supports and devices. I _________________________________________ understand the above statement and agree to submit to the above procedure and accept the risks and consequences of the application.

Sheehan Chiropractic Services Notice of Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. Sheehan Chiropractic Services is required to maintain the privacy and confidentiality of your protected health information, and to provide our patients with notice of our legal duties and privacy practices with respect to your protected health information. Disclosure of your health care information: Treatment We may disclose your health care information to other healthcare professionals within our practice for the purpose of treatment, payment or healthcare operations. For example: “On occasion, it may be necessary to seek consultation regarding your condition from other health care providers associated with Sheehan Chiropractic Services.” “It is our policy to provide a substitute health care provider, authorized by Sheehan Chiropractic to provide assessment and/or

treatment to our patients, with advanced notice, when possible, in the event of your primary health care provider’s absence due to vacation, sickness, or other emergency situation.”

Payment We may disclose your health information to your insurance provider for the purpose of payment or health care operations. The billing statement contains medical information, including diagnosis, date of injury or condition, and codes which describe the health care services received. Workers Compensation We may disclose your health information as necessary to comply with State Workers’ Compensation Laws. Emergencies As required by law, we may disclose your health information to notify or assist in notifying a family member or another person responsible for your care about your medical condition or in the event of an emergency or of your death. Public Health We may disclose you health information to public health authorities for purposes relating to: preventing or controlling disease, injury or disability, reporting child abuse or neglect, reporting elder abuse, domestic violence, or to the FDA regarding food or drug reactions and reporting disease or infection exposure. Judicial and Administrative proceedings: We may disclose you health information in the course of any administrative or judicial proceeding. Law enforcement We may disclose your health information to a law enforcement official for purposes such as identifying or locating a suspect, fugitive, material witness or missing person, complying with a court order or subpoena, and other law enforcement purposes. Deceased Persons We may disclose your health information to coroners or medical examiners. Organ donation We may disclose your health information to organizations involved in procuring, banking, or transplanting organs and or tissues. Research We may disclose your health information to researchers conducting research that has been approved by an Institutional Review Board.

Public Safety It may be necessary to disclose your health information to appropriate persons in order to prevent or lessen a serious and imminent threat to the health or safety of a particular person or to the general public. Specialized Governmental Agencies We may disclose your health information for military, national security, prisoner and government benefits purposes. Marketing We may contact you as described below: Calls: message’s left on your answering machine or with the person answering the phone; no personal health information will be disclosed during this recording or message other than the date and time of your scheduled appointment along with a request to call our office if you need to cancel or reschedule your appointment. It is our practice to participate in charitable events, food donations, “Patient Appreciation Day” etc. During these times we may send you a letter, postcard, invitation or call your home to invite you to participate in the charitable activity. We will provide you with information about the type of activity, the dates, and the times, and request your participation in such event. It is not our policy to disclose any personal health information about your condition for the purpose of Sheehan Chiropractic sponsored fund-raising events. Change of ownership In the event that Sheehan Chiropractic is sold or merged with another organization, your health information or record, will become the property of the new owner. Your Health Information Rights

- You have the right to request restrictions on certain uses and disclosures of your health information. Please be advised that Sheehan Chiropractic is not required to agree to the restriction that your requested.

- You have the right to have your health information received or communicated through an alternative method or sent to an alternative location other than the usual method of communication or delivery, upon your request.

- You have the right to inspect and copy your health information. - You have the right to request that Sheehan Chiropractic amend your protected health information. Please be advised

that Sheehan Chiropractic is not required to agree to amend your protected health information. If your request to amend your health information has been denied, you will be provided with an explanation of your denial reasons and information about how you can disagree with the denial.

- You have the right to receive an accounting of disclosures of your protected health information made by Sheehan Chiropractic.

- You have a right to a paper copy of this Notice of Privacy Practices at any time upon request. Changes to this Notice of Privacy practices Sheehan Chiropractic is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices. Sheehan Chiropractic has the right to amend this Notice of Privacy Practice but until such amendments take place, Sheehan Chiropractic is required by law to comply with this Notice. If you have any questions about any part of this notice please call 415-681-1031 and speak to Dr. Laura Sheehan or make an appointment within 2 working days to have a personal conference. Complaints about your privacy rights or how Sheehan Chiropractic handled your health information can be directed to Laura Sheehan at 415-681-1031. I have received and read this Privacy Notice and sign this in acknowledgement ______________________ On this day_______________.

Philosophical Agreement

Wellness exists when all systems, organs, tissues and cells of the body functions at 100% under the direction of the Innate Intelligence. The Nervous System is the medium used to control and coordinate all body functions. Normal free transmission of neurological impulses between the brain and body is necessary for normal life expression, which is wellness. Subluxations of the spine caused by:

Abnormal motion of a vertebra Abnormal nerve function Muscular imbalances (spasm, tightness, etc.) Improper cell function Pathological process (bone, ligament, disc, life force energy flow)

- can lead to a state of dis-ease and ill-health, which in time may lead to

abnormal life expression, symptoms, sickness and loss of potential wellness. Chiropractic adjustments remove interference to the nervous system caused by the subluxations of the spine. This leads to improves neurology and life expression. Each individual can then function and express life better, have a greater resistance to illness and disease and gain the potential to heal and recover. Chiropractic is not a form of medicine. Medicine specializes in the treatment of diseases. Chiropractic specializes in the restoration and expression of life as we remove subluxations that directly interfere with proper function. I do not diagnose, prognose, treat or cure disease. I do not attack or suppress symptoms. If, during care, you become concerned about your symptoms or your condition, I suggest that you seek the help of a symptom, sickness and disease care professional. My goal is to free the interference caused by subluxations and release the innate power of the body. I, the undersigned, have fully read and understand the above statement and agree to receive chiropractic care with this understanding. Date: ____________ Name ( please print ) ___________________________________ Signature _____________________________________________

Laura Sheehan D.C. 915 Irving Street

San Francisco, Ca 94122 415-681-1031

SHEEHAN CHIROPRACTIC 915 IRVING STREET Phone 415-681-1031

Fee Schedule Initial Exam ………………..…..$120 Limited Exam …………….........$65 Re Exam ………………….........$55 Consult ………………………...$40 Nutritional Counseling ……...…$50 per ½ hr. session Treatments Adjustments ……………………$65, $70 Depends on 1-2, 3 -5 regions of the spine. Extremity adjustment (ankles, wrists, knees) $45 Home Visits ……………………$75-$100 Bowen Myofascial Release…….$60 ($25 w/ adjustment) Cranio-Sacral Therapy ………...$85 per 45min. session Massage ………………………..$85 per 45min. session Babies and Children Initial Exam …………………...$55 Cranio-Sacral Therapy ………..$85 per 45min. session Adjustments …………………...$50 X-Rays - Charges are for EACH VIEW X-RAYED Cervical ………………………$40 Comparative ………………….$40 Thoracic ………………………$40 Lumbar ……………………….$40 Extremity ……………………..$40 X-Ray Marking and Consultation $25 Appointment Reminders You will receive a reminder call or email the day before your appointment is scheduled. The reminder service automatically calls the cell phone number unless you specify otherwise. Yes______call my cell phone with reminders No______call this number with reminders instead ______________________. No______Do Not call to remind me. Email at: __________________________________________ Missed appointments will be subjected to be charged for the full amount of your massage, cranial sacral therapy or chiropractic visit if not notified within 24 hours. Insurance We can supply you with an invoice to submit to your insurance. We accept most PPO insurance plans but are NOT contracted with any company. We do not accept HMO plans. I have read the above rates and agree to them. Signature _________________________________________________