Colleyville Chiropractic
Shockwave New Patient Examination — CVC Spine & Sport
Drive Disconnected
1Demographics
2History
3Consent
4Candidacy
5Exam
6Protocol
7Treatment
8Summary
9Pricing
★ROF
Shockwave New Patient Exam · CVC Spine & Sport
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I'm a Patient
Start or continue your intake paperwork
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Staff / Provider
View waiting patients and resume exams
Staff — Patient Queue
Waiting Room
Patients who have completed their intake. Tap a patient to resume their exam.
Patient data found — resume from candidacy screening
Patient Self-Service — Page 1 of 2
Personal Information
Please complete all fields. Your information is kept strictly confidential.
Patient Information
Emergency Contact
Insurance & Billing
Patient Self-Service — Page 2 of 2
Health & Complaint History
Select all areas of pain. We'll collect details for each.
Areas of Pain / Complaint Select all that apply
Plantar Fasciitis / Heel
Achilles Tendon
Shoulder / Rotator Cuff
Knee / Patellar Tendon
Lateral Epicondyle
Hip / Greater Trochanter
Lumbar / SI
Other
Medical History
None
NKDA
None
None
Health History — Check All That Apply
Patient Self-Service — Consent
Authorization & Consent
Please read carefully, check to acknowledge, then sign below.
HIPAA Notice of Privacy Practices
Colleyville Chiropractic is committed to protecting your health information. We collect and use your personal health information to provide treatment, process payment, and conduct healthcare operations. You have the right to inspect, copy, and request amendments to your records. A full copy of our Notice of Privacy Practices is available at the front desk or upon request. By checking below, you acknowledge receipt of our HIPAA Notice of Privacy Practices.
Consent to Treatment & Office Procedures
I voluntarily consent to chiropractic examination and any treatment deemed clinically appropriate by the treating provider at Colleyville Chiropractic. I understand that care may include, but is not limited to: shockwave therapy (RPWT), chiropractic spinal manipulation and adjustments, soft tissue therapy, electrical stimulation, ultrasound therapy, therapeutic exercise, kinesio taping, and other clinically indicated modalities. The provider will recommend a diagnosis and treatment plan based on examination findings. I have the right to review, discuss, and decline any recommended treatment. I consent to release of medical information necessary for treatment coordination, billing, and insurance verification. No guarantees of specific outcomes have been made.
Shockwave Therapy Informed Consent
What is Shockwave Therapy? Radial Pressure Wave Therapy (RPWT) uses the PINZHIMED PZ-3201M to deliver high-energy acoustic waves into injured tissue. It is non-invasive and drug-free.

During Treatment: You will feel deep tapping or pressure — moderately uncomfortable. A 6–7/10 discomfort level is normal and therapeutic.

After Treatment (24–72 hrs): Expect local soreness. This is a normal healing response. Avoid NSAIDs (ibuprofen, naproxen) for 48 hours. Light movement encouraged; avoid aggressive loading 48 hrs.

Typical Course: 3–10 sessions, 1–2x per week. Most improvement after sessions 3–4. Results vary.

Risks: Temporary soreness, bruising, skin sensitivity. Serious adverse events rare with proper screening.

By signing, I confirm I have read this, had the opportunity to ask questions, and voluntarily consent to shockwave therapy.
Patient Signature
Signature — Sign with finger or stylus
Patient Signature
📋
Thank You!
Your information has been recorded. Please hand this tablet to our front desk staff to continue.
Staff: Enter PIN to unlock
Staff — Candidacy Review
Contraindication Screening
Review all contraindications before proceeding to provider exam.
⛔
Absolute contraindication flagged. Patient is NOT a candidate. Do not proceed — consult provider immediately.
⚠️
Relative contraindication(s) noted. Provider must review before treatment.
✅
No contraindications identified. Patient appears cleared for evaluation.
Absolute Contraindications Any = STOP
Relative Contraindications Provider review
Staff Notes & Decision
Candidacy Decision
✅ Cleared — Proceed
⚠️ Conditional — Provider Review
⛔ Deferred — Not a Candidate
Provider — Clinical Examination
Physical Examination
Condition-specific findings
Overall Clinical Impression
Primary Diagnosis / Finding(s)
Tendinopathy (chronic)
Enthesopathy
Plantar Fasciitis
Calcific Tendinitis
Myofascial Pain Syndrome
Ligament Sprain
Somatic Dysfunction
Post-Surgical Fibrosis
Subluxation Complex
Low Back Pain
Cervicalgia
Rotator Cuff Syndrome
ICD-10 Codes (auto-suggested — tap × to remove, type to add more)
Shockwave / RPWT
Chiropractic Adjustment
E-Stim
Ultrasound
Manual Therapy
Therapeutic Exercise
Kinesio Taping
NeuroPath
Heat / Cold
Visit Calculator
Recommended Visits
6
Based on findings
Session Frequency
1x/wk
2x/wk
5–7 days
Est. Duration
—
at selected frequency
Goals & Re-evaluation
After 3 sessions
At session 5
At 4 weeks
At 6 weeks
Provider Signature
Provider Signature
Provider Signature
Provider — Protocol
Recommended Treatment Protocol
PINZHIMED PZ-3201M — adjusted per region, chronicity, and pain level.
Provider — Treatment Package
Treatment Pricing Builder
Build the patient's treatment package, select payment method, and calculate their cost.
Treatment Tier Select a starting point — customize services below
Good
Essential
Shockwave only
Better
Enhanced
Shockwave + PT
Best
Complete
Shockwave + PT + Adjustment
Service Builder Rates auto-floor to minimums · SW auto-prices at volume
SW Standard $149 SW 5+ visits $110 SW 10+ visits $99 Adj floor $38 PT unit floor $17
Units/Visit
Visits
Rate ($)
Subtotal
Shockwave (RPWT)
Cash only · auto-prices by volume
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Physical Therapy / Therapeutic Exercise (97110)
BCBS allowable $16.40/unit · floor $17/unit · standard $22/unit
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Adjustment 98941 (3-4 regions)
BCBS allowable $22.00 · cash floor $38 · standard $60
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Ext. Adjustment 98943
BCBS allowable $14.54 · cash floor $38 · standard $60
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Payment Method Shockwave is always cash · Insurance applies to PT and Adj only
💵Pay in Full
−10% discount
📅2-Pay In-House
💳CareCredit
🏦HSA / FSA
🩺Insurance
BCBS
📋 Treatment Cost Summary
Select services and payment method above
Provider — Visit Notes
Treatment Received Today
Document all services rendered this visit. Max 3 shockwave regions per session.
Services Rendered Check all performed today
Post-Visit Status
Return next visit
ROF scheduled
Referral given
Discharged
Final — Summary & Export
Clinical Summary
Review, edit the note, then save and export.
Visit Summary
Clinical Note Edit before saving
Day 2 Document
Report of Findings
Review, then print or export for the patient's Day 2 visit.
Report of Findings Preview