• New Patient Intake Form

  • Patient Information

    Please Fill In All Blanks
  •  -  -
    Pick a Date
  •  -
  •  -
  • Current Complaint

    Please Fill In All Blanks
  •  -  -
    Pick a Date
  •    
  • Medical History

    Please Fill In All Blanks
  • Authorization and Consent

    • I confirm that all information given in this form is true, complete, and accurate.
    • I understand that Moore Chiropractic is a cash practice, and that I am required to pay for services at the time they are rendered.  Although Moore Chiropractic will file certain insurance claims as a courtesy, I understand that reimbursement is ultimately between me and my insurance company. 
    • I understand that Moore Chiropractic is soley focused on the detection and reduction of subluxations (segmental dysfunctions), and that I will be referred to an appropriate medical professional if any non-chiropractic findings are encountered during my examination or treatment.
    • I understand that based on the current standard of care, medical imaging is not indicated for new patients unless certain red flag symptoms are present.  If my condition does not show improvement within a reasonable timeline, I may be referred out for medical imaging by my chiropractor.
    • I acknowledge that no assurance was offered about the outcome of care. 
    • I release Moore Chiropractic of any responsibility in case of accident, illness, or injury.
    • I acknowledge that I have received, reviewed, and understand the Notice of Privacy Practices which describes the clinic's policies and procedures regarding the use and disclosure of any protected health information received, created, or maintained in the clinc.
  • Clear
  •  
  • Should be Empty:
Jotform Logo
Now create your own JotForm - It's free! Create your own JotForm