George J. Lubertazzo, DC
39 Meadow Road
P.O. Box 1727
Rutherford, NJ 07070

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.

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
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:

Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Were You Aware That...


I. CONSENT: 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.If any outstanding balance is overdue more than 30 days after I suspend or terminate my care, a finance charge of 18% will be added to overdue balance. If there is a credit card on file with the office, I authorize, by signing below, the use of the credit card for payment for any outstanding balance. --------------------------------------------- II. ASSIGNMENT OF BENEFITS I hereby instruct and direct my insurance company to pay by check made out mailed to this clinic the professional or medical expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for professional services rendered by this clinic. A photocopy of this assignment shall be considered as effective and valid as the original. ------------- III. RELEASE OF INFORMATION I authorize this clinic to release any information pertinent to my case to any insurance company, adjuster, and attorney involved in this case; and hereby release the clinic of any consequence thereof. ------------------------------------------------------------------------------------------------------------------ IV. ACKNOWLEDGMENT OF RECEIPT OF NOTICE As required by the Privacy Regulations of HIPAA, I hereby acknowledge that I have read a current copy of Dr. George J. Lubertazzo, DC Family Chiropractic s Notice of Privacy Practices as posted in the office, revised April, 2020. As required by the Privacy Regulations, the office manager of Dr. Lubertazzo s office was made available to explainthe Notice of Privacy Practices as posted in the office to my satisfaction. As required by said regulations, I am aware that Dr. Lubertazzo has included a provision that reserves the right to change the terms of this notice and to make the new notice s provisions effective for all protected health information that it maintains.Good faith effort to obtain receipt: Patient declined to sign the ACKNOWLEDGMENT of receipt of notice but was made aware of the Notice of Privacy Practice as posted in the reception of the office.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


Finalizing Form

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