New Patient Form

  • New Patient Form

Instead of completing the on-line form below you can use the printed form which does not qualify for the 25% savings on your CHIRO INTRO PACKAGE – to get the printed form either click here to download or visit us when we are open and we will give you the printed form.

CHIRO INTRO PACKAGE

  • complimentary consultation
  • detailed examination
  • report of findings
  • your first service appointment
    (example: chiropractic adjustment)

New patients, SAVE 25% on your CHIRO INTRO PACKAGE when you complete and send the following on-line New Patient Form!!

New Patients Welcome!
Pay as you go – No contracts
Service fees covered with most extended health plans
We can process your health plan claims for you
Doctor referral NOT required
Confidentiality assured

Fields marked with an * are required

HEALTH INFORMATION
Drugs you are currently taking
Is your mattress comfortable?
How do you sleep?
Have you ever been in an auto accident?
Have you had any other personal injury or work-related accident?
Do you smoke or use tobacco?
Do you drink alcohol?
Do you use narcotic drugs?
Do you wear a heel or orthotic insoles
Previous chiropractic care

HEALTH CONDITIONS

Below is a list of conditions which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can effect your overall diagnosis, treatment plan and possibility of being accepted for care.
Have you ever been tested for food allergies?
Check any of the following conditions you have had
Check any of the following you have had in the past 6 months
Musculo-Skeletal Code - in the past 6 months
Nervous System Code - in the past 6 months
General Code - in the past 6 months
Gastro-Intestinal Code - in the past 6 months
Genito-Urinary Code - in the past 6 months
C-V-R Code - in the past 6 months
EENT Code - in the past 6 months
Male / Female Code - in past 6 months
Females Only
Are you pregnant?

CURRENT HEALTH COMPLAINTS

List up to 3 complaints below and answer the following questions regarding each. List your primary complaint as #1.
1d. Rate intensity of this problem: (1 = mild; 10 = extreme)
1j. Is this problem getting better, worse or staying the same?
2d. Rate intensity of this problem: (1 = mild; 10 = extreme)
2j. Is this problem getting better, worse or staying the same?
3d. Rate intensity of this problem: (1 = mild; 10 = extreme)
3j. Is this problem getting better, worse or staying the same?

LIFESTYLE AND SOCIAL HISTORY
Check all that apply

ADDITIONAL INFORMATION

PERSONAL INFORMATION
Gender *

ACCOUNT INFORMATION
Please wait for confirmation message after clicking the send button - if you don't see a confirmation, chances are you have not provided all the required information, please scroll up and resolve any error messages before clicking the send button again.