Chiropractic Health And Wellness Center, LLC
5412 Glenside Drive Suite E
Richmond, VA 23228

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.

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Patient Information

Personal Information
Contact Information
Feet Inches

(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.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

How did you find out about our office?

Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information

Current Symptoms

If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

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:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Social History & Life Choices:


Chiropractic Experience

Please select all that apply.


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:


For Women Only


Health Problems & Concerns:

Please select all that you have had or currently have.

Auto Accident

Visited a Hospital or Doctor?

Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:


TERMS OF ACCEPTANCE When a person seeks chiropractic and rehabilitation health care and is accepted for such care, it is essential for both parties to be working towards the same objective. As a chiropractic and rehab facility we have one main goal, to detect and correct/reduce the vertebral subluxation complex. It is important that each person understand both the objective and the method that will be used to attain this goal. This will prevent any confusion or disappointment.Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method is by specific adjustments of the spine.Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity.Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. Regardless of what a disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. Our Only Practice Objective is to eliminate a major interference to the expression of the body’s innate wisdom and ability to heal. Our only method is specific adjusting to correct vertebral subluxations combined with rehabilitation procedures.NOTE: It is understood and agreed the amount paid to the Chiropractic Health And Wellness Center for x-ray, is for examination only and the x-rays will remain the property of this office, being on file where they may be seen at any time while a patient of this office.CONSENT TO CAREI do hereby authorize the doctors of the Chiropractic Health And Wellness Center to administer such care that is necessary for my particular case. This care may include consultation, examination, spinal adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays or any other procedure that is advisable, and necessary for my health care. Furthermore, I authorize and agree to allow the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic, to work with my spine through the use of spinal adjustments and rehabilitative exercises for the sole purpose of postural and structural restoration to allow for normal biomechanical motion and neurological function.I have had an opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures related to my health care. I understand that I am responsible for all fees incurred for the services provided, and agree to ensure full payment of all charges. I further understand that a fee for services rendered will be charged and that I am responsible for this fee whether results are obtained or not. I understand and am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment including, but not limited to fractures, disk injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts then known, is in my best interest. The doctor will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the spinal structural conditions treated at this clinic. I also clearly understand that if I do not follow the Doctors specific recommendations at this clinic that I will not receive the full benefit from the programs offered, and that if I terminate my care prematurely that all fees incurred will be due and payable at that time. I authorize the assignment of all insurance benefits be directed to the Doctor for all services rendered. I also understand any sum of money paid under assignment by any insurance company shall be credited to my account, and I shall be personally liable for any and all of the unpaid balance to the doctor. I have read or have had read to me, the above consent. I have also had the opportunity to ask questions about this consent, and by signing below I agree to the above-above named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future conditions(s) for which I seek treatment. INSURANCE INFORMATIONI clearly understand that all insurance coverage, whether accident, work related, or general coverage is an arrangement between my insurance carrier and myself. If this office chooses to bill any services to my insurance carrier that they are performing these services strictly as a convenience for me. The Doctors office will provide any necessary report or required information to aid in insurance reimbursement of services, but I understand that insurance carriers may deny any claim and that I am ultimately held responsible for any unpaid balances. Any monies received will be credited to my account.FINANCIAL AGREEMENT I hereby authorize the Chiropractic Health And Wellness Center, LLC (CHAWC) to furnish my insurance company(ies), my attorney(s), and any other legal representatives whom I may designate from time to time, with any records, reports, or other information those parties may request regarding my condition or my course of treatment.I further hereby assign to CHAWC all rights I may have to reimbursement from any insurance companies which do or may provide reimbursement or indemnification for the expenses I may incur from time to time at CHAWC. I understand that CHAWC may notify such third party payers of this assignment in order to arrange for direct payment by the payers to CHAWC, but I further understand that any such arrangements shall be for the sole benefit of CHAWC, and shall create no rights in my favor.I understand that CHAWC processes insurance claims as a courtesy to me, its patient, and not out of any obligation to do so. Under no circumstances shall CHAWC’s processing of any insurance claims be construed as imposing upon CHAWC any obligations to continue pursuing such claims when denied or lost by my insurer, nor to excuse any charges questioned or denied in whole or in part by my insurer. I understand that I remain personally responsible to CHAWC for all charges incurred by me, and that ultimately, the responsibility for securing payment from any third party payers, such as insurance companies, is mine alone.Upon failure by me to pay any charges insured within thirty days of the date the charges are posted to my account, I shall be deemed to be in default of this Financial Agreement. Upon a default, interest shall begin to accrue upon all charges posted to my account at the rate of 1.75% per month (21.00% per annum), compounded monthly. Should CHAWC, in its sole discretion, elect to place my account into the hands of an attorney or third party collection agent, I shall become further liable for all costs of collecting including but not limited to collection agency or attorney’s fees of up to 38% of the total account balance due. I may execute and deliver a copy of this Financial Agreement by facsimile or another means of reproduction, and I authorize CHAWC and any court of competent jurisdiction to rely upon a true copy of my signature in lieu of an original.NOTICE OF PRIVACY PRACTICESAcknowledgement and Consent Acknowledgement and Consent to Use and Disclosure of Protected Health Information Use and Disclosure of your Protected Health InformationYour Protected Health Information will be used by the Chiropractic Health And Wellness Center, LLC or may be disclosed to others for the purpose of treatment, obtaining payment, or supporting the day-to-day health care operations of this office.Notice of Privacy Practices You should review the Notice of Privacy Practices for a more complete description of how your Protected Health Information may be used or disclosed. It describes your rights as they concern the limited use of health information, including your demographic information, collected from you and created or received by this office. You may review the Notice prior to signing this consent. You may request a copy of the Notice at the Front Desk. Requesting a Restriction of Consent on the Use or Disclosure of Your Information• You may request a restriction of consent on the use or disclosure of your Protected Health Information• This office may or may not agree to restrict the use or disclosure of your Protected Health Information.• If we agree to your request, the restriction will be binding with this office. Use or disclosure of protected information in violation of an agreed upon restriction will be a violation of the federal privacy standards.Revocation of ConsentYou may revoke consent to the use or disclosure of your Protected Health Information. You must revoke this consent in writing. Any use or disclosure that has already occurred prior to the date on which your revocation of consent is received will not be affected.

Name of the Insured:
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Patient's/Guardian's signature:


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