Patient Intake Form
Welcome to our online Patient Intake Form. The information
you fill in will be sent directly to our office, speed up your office visit, and
will help us to better serve your healthcare needs. Please take a moment to completely
fill out this form, and upon completion of all form categories click the
[Submit] button at the bottom of this form.
Welcome to our office of chiropractic. Thank you for taking a moment to fill in
our Patient Intake Form. Please fill this form completely
and to the best of your knowledge. Let our staff know if you have any questions.
When complete return it to our office with the bottom authorization checked and
appropriate signatures filled in.
For your protection and security; Navigating away from this form before clicking
the [Submit] button will dismiss all completed
form fields. Successful submission will redirect you to a confirmation page.
Patient Information
Personal Information
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Contact Information
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(We will NOT share your email with any third party. We will only use your email
to contact you in relation to your care with our practice.)
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Draw Your Symptoms
Click on a crayon and draw on the body above to indicate your symptoms
Employment Information
Insurance & Payment for Care
Primary Insurance
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Secondary Insurance
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If an auto accident, please provide:
Personal Health History
Family/Primary Physician
Separate details with "," comma as shown above.
Separate details with "," comma as shown above.
Separate details with "," comma as shown above.
Personal Incident History:
Chiropractic Experience
Please select all that apply.
Other:
If yes…
What was the reason for those visits?
Doctor's Name:
Approximate date of last visit:
Reason for this Visit
If you're only here for chiropractic wellness services please skip this section.
Does this concern interfere with:
Results:
Health Problems & Concerns:
Please select all that you have had or currently have.
Authorization
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 acknowledge and understand that all accounts are the full responsibility of the patient. I understand that deductibles, co pays, co-insurance, and any non-covered services are my responsibility. I agree that all services rendered to me will be charged to me, and that I am 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 Butwin Chiropractic will keep me informed of any outstanding balances owed to the clinic and that any balance not paid within 90 days may be forwarded on to a collection agency. If I am having trouble making payments, I am aware that financial hardships are available and reasonable payment plans can and will be agreed upon by both parties. Pursuant to the Health Insurance Policy and Accountability Act of 1996, I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office’s Notice of HIPAA Privacy Practices for protected health information.
Name of the Insured:
(Please Print)
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_____________________________________________
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Patient's/Guardian's signature:
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_____________________________________________
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Date:
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__________
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Signature