Patient Intake Form - English

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

Emergency Contact

Employer Information

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.


Reason for this Visit

Overall frequency of complaint ( choose one)
Overall intensity of complaint (choose one)
Does your symptoms increase while performing your normal work duties?
Is the purpose of this appointment related to:*
Please select one option
Has this condition
Has this condition occurred before?
Have you seen other doctors for this condition?

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

Experience with Chiropractic 

Health Habits & Conditions

Medications I Now Take:
Health Conditions:
Things I do currently to support my health include:
Do you exercise regularly?*
Please select one option

FOR WOMEN ONLY:

Do you experience painful periods?

Awareness of Chiropractic Principles 
Were you aware that...

Doctors of Chiropractic work with the nervous system?*
Please select one option
The nervous system controls all bodily functions and systems?*
Please select one option
Chiropractic is the largest natural healing profession in the world?*
Please select one option
If Chiropractic care starts at birth, you can achieve a higher level of health throughout life?*
Please select one option

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.

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Authorization for Care:

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

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

Location

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Office Hours

Monday  

8:00 am - 11:00 am

3:00 pm - 6:00 pm

Tuesday  

By Appointment

2:00 pm - 6:00 pm

Wednesday  

8:00 am - 11:00 am

3:00 pm - 6:00 pm

Thursday  

By Appointment

2:00 pm - 6:00 pm

Friday  

8:00 am - 12:00 pm

2:00 pm - 5:00 pm

Saturday  

8:00 am - 12:00 pm

Sunday  

Closed