Southern Chiropractic & Acupuncture
159 Court Square
Huntingdon, TN 38344

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.)

   

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.

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:

For Women Only

COMPLETE THIS SECTION ONLY IF YOU ARE (OR THE PATIENT IS) A WOMAN OVER 16 YEARS OF AGE.

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.




Authorization

INFORMED CONSENT TO CHIROPRACTIC SPINAL MANIPULATION AND CAREI hereby request and consent to the performance of chiropractic adjustments and otherchiropractic procedures, including various modes of physical therapy and diagnostic xrays,on me (or the patient named below, for whom I am legally responsible) by thedoctor of chiropractic named below and/or other licensed doctors of chiropractic whonow or in the future treat me while employed by, working or associated with or servingas back-up for the doctor of chiropractic named below, including those working at theclinic or office listed below or any other office or clinic.I have had the 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.I understand and I am informed that, as in the practice of medicine, in the practice ofchiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able toanticipate and explain all risks and complications, and I wish to rely on the doctor toexercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known, is my best interest.I have read, and or have had read to me, the above consent. I have also had anopportunity to ask questions about its content, and by signing below I agree to theabove-named procedures. I intend this consent form to cover the entire course oftreatment for my present condition and for any future condition (s) for which I seek treatment.

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

Finalizing Form



  1. Submit Form!