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  • NO FEE COVID Testing
  • TeleHealth
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  • New Patient Center
    • What To Expect
    • Online Forms
    • Payment Options
  • News & Articles
  • About Us
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    • Patient Testimonials
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Cunico Health & Wellness
Helping Keep Our Community Safe

NO FEE Covid-19 Testing

Testing Available By Appointment. No Lines, No Wait, No Fee!

Please Note: Once you have completed all Medical Forms you will be redirected to our Covid-19 Scheduler.

Please Note: Form MUST BE filled out with EACH INDIVIDUAL’S Information who will be scheduling a test.

Covid-19

Step 1 of 3

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Name(Required)
Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Address(Required)
Do You Have Insurance(Required)
What type of insurance do you have?(Required)

Uninsured Certification

Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Name(Required)
Address(Required)
Please Acknowledge(Required)

Primary Insurance Carrier

Insurance Address(Required)

Medicare

Below please add your Medicare Information.

Do You Have Secondary Insurance(Required)

Secondary Insurance Carrier

Insurance Address(Required)
Have you or anyone in your household traveled outside of the US in the past 2 weeks (14 days)?(Required)
Have you or anyone in your household traveled outside of this state in the past 2 weeks (14 days)?(Required)
In the past 2 weeks (14 days) have you or anyone in your household had contact with any person suspect-ed to have contracted COVID-19 (including being tested for COVID-19 and being in self isolation for COVID-19)?(Required)
In the past 2 weeks (14 days) have you or anyone in your household been exposed to someone with flu-like symptoms (cough, shortness of breath, or fever)?(Required)
In the past 72 hours have you or anyone in your household experienced cold or flu-like symptoms in-cluding but not limited to:(Required)
By signing below, you certify that the answers above are true. Failure to answer truthfully or withholding information intention-ally will lead to immediate dismissal from this practice and may be subject to applicable laws during this pandemic.

Informed Consent For Procedure

I hereby consent to the performance of medical procedure, including diagnostic x-rays and various forms of physical therapy, diagnostic testing, on me (or on the patient named below, for whom I am legally responsible) by a doctor, NP, RN, Or Medical assistant and or other licensed doctors who now or in the future treat me while employed by, working or associated with or serve as back up for the doctor(s) employed by Cunico Health and Wellness, including those working at the clinic or office listed below or any other office or clinic. I have had an opportunity to discuss with the doctor named below and/or with other office or clinic personnel the nature and purpose of procedures. I understand and am informed that, in the practice of medicine, there are some risks to treatment including, but not limited to sprains, fractures, strokes, disc injuries, and dislocations. I do not expect the doctor to be able to anticipate all the risks and complications, judgment during the course of the procedure which the doctor feels at the time, based upon the facts they know, and is in my best interest. I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about its consent, and by signing below I agree to the above-mentioned procedures. I intend this consent from to cover the entire course of treatment for my present condition and any future condition(s) for which I seek treatment.
Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY

Agreement to Bring Payment If patient paid directly from the Carrier

As a courtesy to our patients, Cunico Health and Wellness will submit insurance claims on your behalf. In some cases, the insurance carrier will make payment directly to the patient. If this is the case, once payment has been made to you or an EOB has been issued by the insurance carrier, we require that you bring such payment along with the entire EOB to Cunico Health and Wellness’ office. If we do not receive payment once you have been paid, you will be responsible to pay the entire open balance in full. By signing below, you agree to bring all checks/Explanation of Benefits to our office.
Date Format: mm/dd/yyyy
Date Format: MM slash DD slash YYYY
Does Cunico Health and Wellness have permission to leave message on your cell phone with the results of your test?

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We will do our best to accommodate your busy schedule. Schedule and appointment today!

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Cunico Health & Wellness

Chiropractic, Pain Laser Therapy, Acupuncture, Weight Loss, Nutrition and Custom Orthotics

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Ideal Protein Weight Loss

Please call ahead to confirm center is open

Monday: 9:00am – 11:00am
Tuesday: 3:00pm – 5:00pm
Wednesday: 8:00am – 12:00pm
Thursday: 2:00pm – 6:00pm
Friday: Closed
Saturday: Closed
Sunday: Closed

Acupuncture

Please call ahead to confirm center is open

Monday: 8:30am – 7:00pm
Tuesday: Closed
Wednesday: 9:00am – 12:00pm
Thursday: 12:00pm – 7:00pm
Friday: Closed
Saturday: 8:00am – 11:30am
Sunday: Closed

Office Wellness

Please call ahead to confirm center is open

Monday: 9:00am – 7:00pm
Tuesday: Closed
Wednesday: 9:00am – 12:00pm
Thursday: 12:00pm – 7:00pm
Friday: 9:00am – 12:00pm
Saturday: 8:00am – 10:30am
Sunday: Closed

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