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
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?
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:
Family Health History
Separate details with "," comma as shown above.
(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol,
etc.)
Social History & Life Choices:
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:
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.
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 (we) agree to pay for services rendered by the above mentioned patient as the charge is incurred. I understand and agree that health & accident insurance policies are an arrangement between an insurance carrier and myself and that I am personally responsible for payment of any and all services covered or not covered. I also understand that if I suspend or terminate my care and treatment, any fee for professional services rendered by me will be immediately due an payable.
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