Spinal Source Chiropractic
6546 Hampton Roads Parkway
Ste 112
Suffolk, VA 23435
(757) 296-BACK (2225)

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?

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.

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


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:


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. Co-pays are due at the time of each visit. I will provide Spinal Source Chiropractic with 24-hour notice if I cannot make my scheduled appointment. If I fail to do so, I understand a fee of $25 may be applied to my account and I am responsible to pay this fee within 30 days of its application. If balances are not paid according to the terms, then the account will be considered past due. If Patient’s account becomes more than thirty (90) days past due, Patient further understands and agrees that should Spinal Source Chiropractic be awarded judgment relating to this contract or any debt incurred thereof, Patient will pay judgment interest of, eighteen percent (18%) per annum, beginning on the date of the judgment. It is further understood and agreed that if this account or any debt owed to Spinal Source Chiropractic is referred to a collection agency or attorney, Spinal Source Chiropractic agrees to pay, in addition to the balance of the account (which includes, but is not limited to, principal, accrued interest, and late charges), all collection fees in the amount of thirty-five percent (35%) of the total unpaid balance due, plus court costs and filing fees incurred by Spinal Source Chiropractic. Patient agrees to pay the aforesaid costs of collection whether or not suit is filed. Patient agrees that the County of Henrico, Virginia shall be the proper venue for any action brought pursuant to this agreement. A photocopy of this contract shall be considered as valid as the original. I agree and authorize the Practice and its agents to contact me by telephone or text message at any phone number associated with my account, including wireless telephone numbers. I further authorize Spinal Source Chiropractic and its agents to contact me via email. I further authorize Spinal Source Chiropractic and its agents to contact me using any method of contact available including but not limited to using pre-recorded or artificial voice messages and/or use of an automatic dialing device, as applicable.

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

Finalizing Form

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