Sample New Patient Form

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Please read the information on this web page to help make your first visit to our practice as smooth as possible. You'll find all the practical information you need, such as a map and directions to our office(s), practice hours, payment policies, and more. You can also save some time by printing out and completing the new patient forms in advance of your appointment.

(Long Demo) New Patient Questions

Name(Required)

First Middle Last

Cell Phone

Alternate Phone

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Email(Required)

Date of Birth

Marital Status

Married

Single

Divorced

Widow

Spouse's Name

Number of Children

Please enter a number from 0 to 20.

Occupation

Employer

Work Address

Street Address City State / Province / Region ZIP / Postal Code Country

Who may we thank for referring you to our office?

Have you ever had Chiropractic care before?

Yes

No

Date of Previous Chiropractic Care

Is this injury or illness related to an auto accident?

Yes

No

Date of Auto Accident

Location of Auto Accident

Your Auto Insurance Company

Your Auto Insurance Contact Phone#

Your Auto Insurance Policy#

Third Party Auto Insurance Company

Third Party Auto Insurance Phone #

Third Party Autop Insurance Policy#

Due to changes in health insurance fees, patient courtesy billing has become a much more cost effective way for you, the patient to get reimbursement for your care. Self-billing allows us to keep our fees low so you can get the care you need without any added cost. Therefore, our policy is that all payment is due at the time of service and bills will be electronically submitted to your insurance provider. All payments from your insurance provider will be mailed directly to you. Statements after submission will be provided upon request.

Do you have any health insurance you would like us to check the benefits on?

Yes

No

Method of payment:

Check

Cash

Credit Card

Why Chiropractic? People go to Chiropractors for a variety of reasons. Some go for Symptomatic relief of pain or discomfort (Relief Care). Others are interested in having the cause of a problem as well as the symptoms corrected and relieved (Corrective Care). Your Doctor will weigh your needs and desires when recommending your treatment program. Please Circle the type of care that best meets your needs.

Relief Care. Relief care is that care necessary to get rid of your symptoms or pain, but not the cause of it. It is the same as drying a floor that was getting wet from a leak, but not fixing the leak.

Corrective Care. Corrective Care differs from relied care in that the goal is to get rid of the symptoms or pain while correcting the cause of the problem. Corrective care caries in length of time but is more lasting.

Authorize(Required)

I authorize DEMO Chiropractic and Laser center Inc to render services to me and I am responsible for all charges incurred.

Patient Signature

Signing Date

Guardian or Spouse’s authorizing care

Please Mark In The Diagram Where Your Problems Are

What hurts and how long has it hurt?

Add as much description as you like.

List your chief complaints in order of severity.

List as many complaints as you like.

List other Chiropractic or Medical Doctors you have consulted for these conditions.

Check any of the following you have had in the last six months:

Are you pregnant?

Yes

No

Not sure

By submitting this form you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks.(Required)

I Agree

Sample New Patient Form

(Long Demo) New Patient Questions

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