New Patient Form

About You

Gender

Emergency Contact Information

Insurance Information

Do you have Insurance?

Referral Information

Are You Working with an Attorney?

How Did You Hear About Us?

Reason for Visit

How long have you had this complaint?

On a scale of 1 to 10, with 10 being the most severe, how would you rate your current level of discomfort?

How often do you feel this discomfort?

How has this complaint changed since the onset?

Current Health

Other than the information already provided, do you have additional health concerns involving any of the following?

Muscles, Bones, or Joints

Nerves, Headaches, Dizziness, or Emotional

Head, Eyes, Ears, Nose or Throat

Heart, Blood Pressure, or Circulation

Shortness of Breath, Coughing, Asthma or Lung Condition

Stomach, Bowels or Digestive Conditions

Genital, Bladder, or Urinary Conditions

Diabetes, Thyroid or Glandular Conditions

Skin or Bleeding Conditions

Allergies or Sensitivities

Personal and Family History

Have you had any surgical procedures?

Are there any past illnesses or conditions we should be aware of?

Do you have a past history of accidents or trauma?

Are there any past illnesses or conditions we should be aware of?

Are you presently taking any medication?

Do you have a past family illness history, such as diabetes, cancer, hypertension, and progressive neurological diseases that we should be aware of?

Work and Social Habits

Current work habits: select all that apply

Personal social habits: select all that apply

Present exercise habits: select all that apply

Diet and nutrition habits: select all that apply

Informed Consent to Treatment

I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit.

I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me.

I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I'm responsible for timely payment of such services.

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.