Patient Forms

Personal History form to complete

Click Here to view and print Personal History Form PDF

Please print this form, fill it out and bring it to us on your initial visit.

 

When filling out the Personal History, you will be asked about physical, chemical, and emotional stressors that go as far back as the womb. We believe that whatever goes to the back of your mind goes into the spine, and that the position, tone, and tension of your spine is determined by the past and present stresses in your life and how well you have adapted to these stresses. Stresses in your life may affect the health of your spine and nervous system. The good news is that when your spine changes, your life changes, and on your first visit you will have an opportunity for a happier and healthier spine and life. Do your best at filling out the Personal History form, and the Doctor of Chiropractic will go over it with you on your initial visit.

 

Informed Consent to Receive Networks Spinal Analysis (NSA) Care

Click Here to view, print, and sign Informed Consent to Receive Network Spinal Analysis (NSA) Care PDF

Please read this form, print and sign it, then bring it to us on your initial visit.

 

Special Notice for Medicare and Insurance Patients

Click Here to view, print, and sign the Special Notice for Medicare and Insurance Patients.

Please read this form, print and sign it, then bring it to us on your initial visit.

 

Privacy Practices

Click Here to view our Notice of Privacy Practices PDF

Click Here to print, fill out and sign the Notice of Privacy Acknowledgement & Authorization

Please print this form, fill out and sign it, then bring to us on your initial visit.

 

Heal, Vitalize, Love and Live Fully!

Consultation, Spinal Exam and Two Network Adjustments ($150 value)

Heal, Vitalize, Love & Live Fully