Stamford Sports & Spine
1 Atlantic Street
Suite 201
Stamford, CT 06901

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

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.)

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:

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


Health Problems & Concerns:

Please select all that you have had or currently have.


I certify that I am 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 hereby consent to the collection and use of the above information to Stamford Sports & Spine (SSS). I authorize this office and its staff (who nor or in the future treatment me while employed by, working or associated with SSS) to examine and treat my condition as the doctors see fit, including various modes of physical therapy, chiropractic procedures, and diagnostic x-rays. 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. With this consent, Stamford Sports & Spine (SSS) may call my home or other alternative location I provide and leave a message on voicemail or in person in reference to any items that assist the practice in carrying out treatment, payment, and healthcare operations (i.e. appointment reminders, insurance items, etc). SSS may use and disclose Health Information for your treatment and to provide you with treatment-related health care services to doctors, nurses, technicians, or other personnel, including people outside the office, who are involved in my medical care and need the information to provide me with medical care. SSS may use and disclose Health Information so that they or others may bill and receive payment from me, an insurance company, or a third party for treatment and services received. SSS will disclose Health Information when required to do so by international, federal, state, or local law. If I am involved in a lawsuit or a dispute, SSS may disclose Health Information in response to a court or a court administrator order. SSS also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell me about the request or to obtain an order protecting the information requested. By subscribing my name below, I acknowledge receipt of a copy of this notice, and my understanding and my agreement to its terms.

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


Finalizing Form

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