New Patient Forms

In order to save you time, please print out and fill out all the appropriate forms before coming to the office. Feel free to call us with any questions that you may have. Having the forms ready when you come to the office will enable us to keep our appointment schedules and minimize your time away from your home or work. Please read the lists below carefully to accurately categorize yourself. If you need any help, please contact the office at 524-1234.


1) Private Pay Patients or Patients without Insurance
If you prefer private payment without insurance, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• General Chiropractic Intake Form
• Pain Drawing

2) Group or Individual Insurance (Most Insurances accepted)
If you any type of Insurance that you wish us to file on your behalf, excluding United Healthcare or Medicare, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• General Chiropractic Intake Form
• Pain Drawing

SECONDARY INSURANCE - Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.

3) United Health Care Insurance
If you have United Healthcare insurance you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• ACN PHQ
• Back Index
• Neck Index
• Financial Policy
• Registration Form
• General Chiropractic Intake Form

4) Medicare Insurance Forms
If you have Medicare Insurance, please fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• General Chiropractic Intake Form
• Pain Drawing

5) Personal Injury Forms
If you have been injured by an accident, other than an Occupational or Motor Vehicle accident, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• Pain Drawing
• Personal Injury

6) Motor Vehicle Accident Forms
If you have been injured by a Motor Vehicle accident or have been involved in an auto accident, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• Pain Drawing
• MVA Intake

7) Occupational Injury Forms
If you have been injured on the job or if your injury is a result of your occupation, you are required to fill out these forms. Included with these forms is a “Back Pain Index” form and “Neck Disability Index” form; if you are experiencing neck or headache pain, please fill out the “Neck Disability Index” form, but if you are experiencing any other pain from back to limb pain, fill out the “Back Pain Index” form. Please print and fill out the following forms.

• Back Index
• Neck Index
• Financial Policy
• Registration Form
• Pain Drawing
• Occupation Injury

8) Massage /Reflexology Intake Form
If you are interested in using our Massage Therapy/Reflexology services to relax and rejuvenate, please fill out this form.

• Massage Reflexology Intake

9) Personal Training Form
If you are interested in utilizing one of our personal trainers to help you during your exercise regimen, please fill out this form.

• Personal Training Form

10) Returning Patients
Please fill out the category of forms above that best pertains to you.

11) Medical Patient Forms
If you are seeking care from one of our medical practitioners, please fill out these forms. If you were involved in a motor vehicle accident, occupational injury, or personal injury (ex. Slip and fall), please fill out forms 5, 6, or 7 above as well. Please print and fill out the following forms.

• Financial Policy
• Registration Form
• Medical Intake Form

12) Hippa Policy and Procedures
This form informs you of your rights and privileges as a patient and to fully disclose our policies with regards to distribution of your patient information.

• Hippa Policy and Procedures