Carolina Chiropractic
Dr. John Adam Petty
655 S. Bennett St, Unit 1
Southern Pines, NC 28387

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

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:

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?

Family Health History

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

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


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.

Electronic Health Record (EHR) Information

Preferred Language: Ethnicity:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered


Carolina ChiropracticFinancial/Privacy Policy and DisclaimerInsurance Verification• Insurance verification is not a guarantee of payment. Verification is only a quote of patient benefits. Insurance companies review charges individually and make payment accordingly. Charges not covered by insurance are the patient’s responsibility.Deductible Payments• It is our policy to collect at time of service. Once we receive an “Explanation of Benefits” report from the patient’s insurance company, we will bill or credit the account for the remaining balance. Reimbursement checks can be issued upon request.Collection of Patient Balance• Co-payments and Co-insurance is the patient’s responsibility and will be collected at time of service.• If the “Explanation of Benefits” report shows the patient has an outstanding balance from services not covered by the individual insurance company, patients will receive a bill outlining these outstanding charges. Upon receipt, payment is due within 30 days. After 30 days, it is the clinic’s policy to turn unpaid accounts over to a collections agency. Legal fees incurred from the collections process are the responsibility of the patient in addition to the previous balance. If payment is not taken care of at time of visit a late fee will incur.Returned Checks• It is our policy to collect $25.00 for checks that are returned to us. This is to cover any fees that apply from the transaction.Appointments• If unable to keep an appointment, as a courtesy to our staff and other patients, please give 24-hour notice when possible. If it is a continual problem there will be a $20 charge added towards your account each visit is missed. The patient will be responsible for payment.Financial Policy Questions• We are happy to address questions regarding your account at any time. Please direct all accounting questions to our staff.HIPPA Privacy Policy• A copy of the HIPPA Notice of Privacy Policy is available upon request.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 doctor sees fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of the 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 for such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and the patient. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

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


Finalizing Form

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