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New Patient Forms

We offer our paperwork online so you can complete it in the convenience of your own home.


Third Party Insurance

This let’s us know what’s happened, but perhaps more important, where do you want to take your health?

Patient Demographics: pdf iconDownload & Print Form

Office Policies: pdf iconDownload & Print Form

Informed Consent: pdf iconDownload & Print Form

Receipt of Privacy Practices: pdf iconDownload & Print Form

Authorization to Pay: pdf iconDownload & Print Form


Automobile Accident

If your health issue is the result of a car accident, we need some additional information.

Personal Injury Protection: pdf iconDownload & Print Form

Health Reports and Doctor’s Lien: pdf iconDownload & Print Form

Health Benefits Affidavit: pdf iconDownload & Print Form


Medicare

If you are a medicare beneficiary, this form lets you know that the initial examination with a chiropractor is not covered by medicare and you will be billed personally for this procedure (even if you have a medicare secondary insurance). This is a medicare rule, not ours.

Medicare Advanced Beneficiary Notice: pdf iconDownload & Print Form


Release of Records

Release of Records: pdf iconDownload & Print Form


Functional Medicine Questionnaires

Detox Questionnaire: pdf iconDownload & Print Form

Sensitivity Questionnaire: pdf iconDownload & Print Form

Environmental Influences: pdf iconDownload & Print Form

Nutritional Assessment Questionnaire: pdf iconDownload & Print Form


Free AdobeReader®

Get adobe readerEach form is a PDF document file. If you do not already have AdobeReader® installed on your computer, click the Adobe® image to download for free.