New Patient Forms

To ensure a smooth and efficient first visit, we ask all new patients to complete the New Patient Registration Form before their appointment. You can conveniently fill out the digital form online, which will automatically be submitted to our office. Alternatively, if you prefer, you can download and print a copy of the form to complete at home and bring it with you to your first visit. This helps us streamline your check-in process and allows our team to focus on providing you with the best possible care from the moment you arrive.

Click here to download a printable version

New Patient Registration Form

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PATIENT INFORMATION

Date*

MM slash DD slash YYYY

SS/HIC/Patient ID #

Last Name*

First Name*

Middle Initial

Address*

City*

State*

Zip*

Email*

Sex*

Age

Birthdate*

MM slash DD slash YYYY

Marital Status*

Married

Separated

Divorced

Widowed

Single

Partnered

Minor

If Partnered for how many years?

Occupation*

Patient Employer/School*

Employer/School Address*

Employer/School Phone Number*

Spouse's Name

Spouse's Birthdate

MM slash DD slash YYYY

SS#

Spouse's Employer

Who can we thank for referring you?

PHONE NUMBERS

Home Phone

Cell Phone*

Best time and place to reach you?

EMERGENCY CONTACT

Name*

Relationship*

Phone*

Work Phone

PATIENT CONDITION

Reason for visit*

When did your symptoms appear?*

Is this condition getting progressively worse?*

Yes

Unknown

What area of your body are you experiencing pain, numbness, or tingling?*

Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)*

Type of pain*

Sharp

Burning

Dull

Tingling

Throbbing

Cramps

Numbness

Stiffness

Aching

Swelling

Shooting

Other

How often do you have this pain?*

Is it constant or does it come and go?*

Does it interfere with your*

Work

Sleep

Daily Routine

Recreation

Activities or movements that are painful to perform*

Sitting

Standing

Walking

Bending

Lying

INSURANCE

Who is responsible for this account?*

Relationship to patient*

Insurance Co.*

ID#*

Is patient covered by additional insurance?*

Yes

Subscriber's Name

Birthdate

MM slash DD slash YYYY

SS#

Relationship to Patient

Insurance Co.

Group #

ACCIDENT INFORMATION

Is condition due to an accident?*

If so, date of occurance

MM slash DD slash YYYY

Type of accident

Auto

Work

Home

Other

Attorney name if applicable

HEALTH HISTORY

What treatment have you already received for your condition?

Medication

Surgery

Physical Therapy

Chiropractic Services

None

Other

If other please explain

Name and address of other doctor(s) who have treated you for your condition

Date of last Physical Exam

MM slash DD slash YYYY

Date of last Spinal X-Ray

MM slash DD slash YYYY

Date of last Blood Test

MM slash DD slash YYYY

Date of last Spinal Exam

MM slash DD slash YYYY

Date of last Chest X-Ray

MM slash DD slash YYYY

Date of last Urine Test

MM slash DD slash YYYY

Date of last Dental X-Ray

MM slash DD slash YYYY

MRI, CT-Scan, Bone Scane

MM slash DD slash YYYY

Please check if you have had any of the following

Conditions 1

AIDS/HIV

Alcoholism

Allergy Shots

Anemia

Anorexia

Appendicitis

Arthritis

Asthma

Bleeding Disorders

Breast Lump

Bronchitis

Bulimia

Cancer

Cataracts

Chemical Dependency

Chicken Pox

Conditions 2

Diabetes

Emphysema

Epilepsy

Fractures

Glaucoma

Goiter

Gonorrhea

Gout

Heart Disease

Hepatitis

Hernia

Herniated Disk

Herpes

High Blood Pressure

High Cholesterol

Kidney Disease

Conditions 4

Liver Disease

Measles

Migraine Headaches

Miscarriage

Mononucleosis

Multiple Sclerosis

Mumps

Osteoporosis

Pacemaker

Parkinson's Disease

Pinched Nerve

Pneumonia

Polio

Prostate Problem

Prosthesis

Psychiatric Care

Rheumatoid Arthritis

Conditions 3

Rheumatic Fever

Scarlet Fever

Sexually Transmitted Disease

Stroke

Suicide Attempt

Thyroid Problems

Tonsillitis

Tuberculosis

Tumors, Growths

Typhoid Fever

Ulcers

Vaginal Infections

Whooping Cough

Other condition not listed

Exercise*

None

Moderate

Daily

Heavy

Work Activity*

Sitting

Standing

Light Labor

Heavy Labor

Habits*

Smoking - Packs/Day

Alcohol - Drinks/Weel

Coffee/Caffeine Drinks - Cups/Day

High Stress Level - Reason

Are you pregnant?*

If yes, due date

MM slash DD slash YYYY

Injuries/Surgeries you have had (include date of occurence)

Falls

Head Injuries

Broken Bones

Dislocations

Surgeries

Medications*

Allergies*

Vitamins/Herbs/Minerals*

Pharmacy Name

Pharmacy Phone

CHIROPRACTIC INFORMED CONSENT

HIPAA Consent*

The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

This consent was signed by (patient's printed name)*

Signature and Date (to be signed in office)

CHIROPRACTIC INFORMED CONSENT

Patient Name*

It is important you understand the information contained in this document. If anything is unclear, ask questions before you sign.

The nature of the chiropractic adjustment

The primary treatment used in this office is spinal manipulative therapy. The doctor's hands or a mechanical instrument will be used on your body in such a way as to move your joints. This may cause an audible "pop" or clicking noise, such as you have experienced when cracking your knuckles. You could also feel a sense of movement.

Analysis/Exam/Treatment

As part of the analysis, exam, and treatment, you are consenting to the following procedures as necessary:

• Spinal manipulation
• Range of motion testing
• Muscle strength testing
• Palpation
• Orthopedic testing
• Basic neurological testing
• Radiographic studies

The material risks inherent in chiropractic adjustment

As with any healthcare procedure, there are certain complications that can arise during chiropractic manipulation and therapy. These complications include but are not limited to: fracture, disc injuries, dislocations, muscle strain, cervical myelopathy, costovertebral strains and separations. Some types of manipulations of the neck have been associated with injuries to the arteries in the neck leading or contributing to serious complications including stroke. Some patients will feel some stiffness or soreness following the first few days of treatment. The doctor will make every reasonable effort during the exam to screen for contraindications to care.

The probability of these risks occurring

Fractures are rare occurrences and generally result from some underlying weakness of the bone which the doctor will ask about during history and exam. Stroke has been the subject of much disagreement; the incidences of stroke are exceedingly rare and are estimated to occur between 1:1Million and 1:5Million cervical adjustments. The other possible complications are also described as rare.

This consent was signed by (printed name)*

Signature and Date (to be signed in office)

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