New Patient Intake Form
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  • New Patient Intake Form

  • Welcome to Cipriani Chiropractic!

    After you fill out the new patient form, be sure to BOOK YOUR APPOINTMENT!

    Call (leave a message), Text, Email, or you can BOOK ONLINE. 

    Look forward to your visit. 

  • Gender*

  • Contact Information

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  • Preferred method of contact (We use this to confirm all appointments)*

  • Emergency Contact

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  • Thank You For Choosing Cipriani Chiropractic!

  • Have you ever received a chiropractic adjustment?*

  • Tell Us What You’re Experiencing

  • What is your main complaint? This is the symptom that you are most concerned about*

  • My main complaint*

  • How did this begin?*

  • How often do you experience this problem?*

  • Regarding your main complaint, IN THE PAST 4 WEEKS how would you rate the severity of the pain ON AVERAGE on a scale of 0-10 with 0 being no pain and 10 being worst pain ever*
  • Regarding your main complaint, IN THE PAST 4 WEEKS how would you rate the severity of the pain AT IT’S WORST on a scale of 0-10 with 0 being no pain and 10 being worst pain ever*
  • Please describe the type of pain you’re experiencing*

  • Regarding your main complaint, IN THE PAST 4 WEEKS how has the pain NEGATIVELY AFFECTED YOUR DAILY LIFE on a scale of 0-10 with 0 being no affect at all and 10 being extremely affected*
  • What imaging studies, if any, have you had for this problem? Check all that apply.*

  • Please click the box next to ALL symptoms you’ve experienced in the last year*

  • Patient Health History Information

  • How would you describe your current level of health?*
  • Have you recently had an accident or injury? (within last 6 months)*
  • Have you had ANY surgeries within the last 6 months? (including cosmetic, eye or dental)*
  • Do you have cancer?*
  • Are you currently pregnant or post-partum?
  • Do you have any contageous skin conditions?*
  • Do you have any spinal defects that you are aware of?*

  • Do you have, or have you had, any cardiovascular issues?*

  • Do you have any of the following conditions?*
  • Do you have any of the following conditions (cont')*
  • Are you taking any prescription medications?*

  • Family History

  • Help Us Serve You Better!

  • General Policies

    Locations we service: Our office is location in Sewell, New Jersey at 111 egg harbor road, suite B, 08080. All are welcome to Cipriani Chiropractic! 
    Appointment verification: We verify every appointment by text message unless an alternative contact method is requested. 

    Be prepared and on time: We will be prepared and on time for your appointment and ask the same of you. You have a dedicated time slot based on the session type that you choose. Your appointment starts at your scheduled appointment time so we please ask that you be on time. 

    Canceled or missed appointments: Please give 24 hr or "day before" notice for an appointment that needs to be canceled or rescheduled. If appropriate notice is not given, you will be charged the full price of your visit.

    Right of refusal: We reserve the right to refuse service to anyone at any time for any reason.

  • Financial Policies
    Fees: Our fees are located on our website. By clicking "I agree" at the end of this form, you are agreeing to the fees as listed.

    Payment methods: All payments are due prior to, or at the time of your appointment. Payments can be made by cash, local check or credit card. Checks not honored by your bank will be subject to an additional $30 fee.

    Health insurance: We do not accept health insurance and do not assist with any attempt at reimbursement for our services.

    Refunds: Completed appointments are not refundable.

    Receipts: Receipts are available by email when requested.

    Additional fees: Additional fees may apply for appointments outside of our normal service area or normal hours. However, we are 100% transparent with our fees and you will never be charged an additional fee without discussing and agreeing to these fees with Dr. Cipriani.

    BROKEN APPOINTMENT / NO-SHOWS - If you're unable to keep an appointment for any reason, we require that you give up 12 hour notice. MISSED appointments without prior notification are subjected to a charge of %100 of visit coast. 

     

  • Privacy Policies
    Our privacy policies can be found on our website. You can also request a copy of privacy policies which will be send by email only.

  • Social Media Consent

    (Adjustments are only filmed if previously discussed or agreed upon)

    I hereby give Cipriani Chiropractic permission to take photographs, videos, and testimonials of me for the purpose of marketing on Cipriani Chiropractic’s social media platforms including Facebook, Instagram, YouTube, and their clinic website.

    I hereby release and discharge, and hold harmless, Cipriani Chiropractic from any and all claims arising out of use of the photos, videos, or testimonials.

     

  • Social Media Consent
  • ^ If you have given consent

  • Informed Consent For Treatment
    Congratulations on choosing one of the safest and most natural health care programs available! 

    In accordance with New Jersey state law, this notice is to inform you, as a patient, of the material risks of undergoing chiropractic care and/or physiotherapeutic rehabilitation. Material risk means that there are known inherent risks from a particular treatment and certain complications, though improbable, could occur. These rare complications include, but are not limited to, minor muscle strains, intervertebral disc compromise, fractures, dislocations, skin irritation, and cardiovascular accidents. I understand my doctor will not be able to anticipate all potential complications, but elect to rely on his/her clinical expertise and judgment to determine courses of clinical action, based upon known facts, which are considered in my best interest.

    I have read and understand the preceding statements and hereby consent to voluntarily participate in chiropractic care and/or physiotherapeutic rehabilitation procedures as deemed appropriate by my doctor. If at any time I decide that I am unwilling to engage in these procedures, I reserve the right to inform my doctor of such and not participate in these forms of evaluation and treatment. I understand that results are not guaranteed and that I have the opportunity to discuss the purposes and risks associated with all recommended evaluation and treatment procedures at any time.

  • By clicking "I agree" below you are acknowledging that all of the information in this form was completed accurately and honestly and that you have read and agree to our "Policies" and "Informed Consent For Treatment"

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