New Patient Forms

Patient Forms

This let’s us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know! Please Click-On the section below as what is your concern, and simply print the page(s). Complete the questions in the comfort of your home or office and bring with you to your appointment!

1. General Patient Information Forms

• Patient Intake Form
• Terms of Acceptance
• X-Ray Female Consent
• Pain Questionnaire
• HIPPA Form

2. Patient Form Child Age 5 and Under

• Pediatric History Form
• Consent to Treatment of Minor Child
• HIPPA Form

3. Websters In-Utero Constraint Technique Form

• The Websters In-Utero Constraint Technique
• Confidential Patient Information Form
• Terms of Acceptance
• HIPPA Form

4. Automobile Accident / Injury Forms

• Accident Injury Form
• Confidential Patient Information Form
• Financial Agreement Form
• Terms of Acceptance
• Pain Drawing Diagram
• Neck Disability Index
• Pain Questionaire
• Assignment of Benefits
• Systems Review Form

5. Vibration Plate Information

• Whole Body Vibration (What is it?)