EHR Form

Electronic Health Records Intake Form
Name:

First NameLast Name
Phone Number
Please enter a valid phone number.
Email:
example@example.com
Preferred method of communication (choose one):

EmailPhoneMail
DOB:

MonthDayYear
Date
Sex:

MaleFemale
Preferred language (circle one):

EnglishSpanishOther
Smoking Status (choose one):

Every DayOccasionalFormerNever
Race:
Ethnicity:
Height: ft in. Weight:
List any medications you are currently taking and frequency:
I choose to decline receipt of my clinical summary after every visit:

Yes
Signature of Policy Holder *

Clear
Date

MonthDayYear
Date
North Rockland Chiropractic 54 S. Liberty Dr, Stony Point, NY 10980 (845) 429-2663

BP:______/______
Should be Empty: