New Patient Form

When a person seeks chiropractic health care and we accept a person for such care, it is essential for both to be working towards the same objective.

Chiropractic has only one goal. It is important that each person understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment.

Adjustment: An adjustment is the specific application of forces to facilitate the body’s correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine.

Health: A state of optimal physical, mental, and social well being, not merely the absence of disease or infirmity.

Vertebral Subluxation: A misalignment of one of the 24 vertebra in the spinal column that causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body’s innate ability to express its maximum health potential.

We do not offer to diagnose or treat a disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of another health care provider.

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body’s innate wisdom. Our only method is specific adjusting to correct vertebral subluxations.

TELL US ABOUT YOURSELF
Name *
Name
Date of Visit
Date of Visit
Address
Address
Home phone
Home phone
Cell phone
Cell phone
Work phone
Work phone
Date of Birth
Date of Birth
Status
Have your children ever been checked by a chiropractor?
HEALTH INFORMATION
RATE YOUR STRESS
RATE YOUR STRESS
Physical Stress (ex: heavy lifting, excessive driving, computer work)
Chemical Stress (ex: exposure to toxins, medications, poor nutrition)
Emotional Stress (ex: work, family, financial)
FOR WOMEN
Are you taking birth control pills?
Are you pregnant?
HIPAA PRIVACY PRACTICES
I authorize my health care provider to use a telephone system and/or email to use my name, address and phone number, the name of my schedules treating chiropractor, and the time and place of my schedules appointment(s) for the limited purpose of contacting me to notify me of a pending appointment or other health related communications. I also authorize my health care provider to disclose to third parties who answer my phone limited protected health care information regarding pending appointments and to leave a reminder message on my voice mail system and/or answering machine.
I have read and agree to the above HIPAA compliance statement. *
CONSENT TO EVALUATE & ADJUST A MINOR CHILD