• NEW PATIENT INTAKE FORM

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • DOB
     - -
    2 digit month, 2 digit day, 4 digit year
  • Gender:
  • Marital Status:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Preferred Method of Contact?
  • May we leave messages at this number?(Home Phone Number)
  • May we leave messages at this number?(Cell Phone Number)
  • May we email you with appointment related information (paperwork updates, exercises, etc.)?
  • Appointment Reminders: Germantown Chiropractic, PSC may employ a third party automated outreach and messaging system to use my personal information for the purpose of notifying me of upcoming appointments at the following numbers/email address as detailed above:

  • Emergency Contact:

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Insurance Info:

  • Other Insurance:

  • Are your symptoms a result of:
  • Have you had any spinal x-rays of the area of complaint?
  • Have you had any MRI’s or CT scans of the area of complaint?
  • How often do you notice the pain?
  • Describe your complaint (Circle all that apply):
  • Do you have any of the following?

  • HEALTH HISTORY

  • Please read through the list and check the box next to each condition that applies to you.

  • Musculoskeletal - General
    Rows
  • GI/GU/Endocrine
    Rows
  • Nervous System
    Rows
  • Cardio-Pulmonary
    Rows
  • EENT
    Rows
  • Injuries and General
    Rows
  • Pregnant or could be pregnant?

  • Past/Social/Family History

  • Family History:

  • Select all that apply
    Rows

  • Social History:

  • Selecy all that apply to you

  • Caffeine Use:
  • Drink Alcohol:
  • Chew Tobacco:
  • Cigarettes:
  • Exercise:
  • How long do you exercise?

  • Appointment Policy:

    If you are more than 5 minutes late for an appointment, you may be asked to reschedule or wait until there is an opening in the schedule. You will be charged a $25 missed appointment fee if you do not cancel within 24 hours of your appointment. You will only be charged this amount on your 3rd offense to allow for uncontrollable circumstances. If you have an insurance policy that does not allow missed appointment fees, you may be dismissed as a patient or only allowed to schedule same day appointments in the future. I have read, understand, and accept the appointment policies as outlined above.

  • HIPAA Privacy Practices

  • Would you like a copy of our Notice of Privacy Practices?

  • I acknowledge that I have received and /or have been given the opportunity to review this Chiropractic Office’s Notice of HIPAA Privacy Practices for protected health information.

  • List of People who may have access to your medical records:

  • I certify that I’m the patient or legal guardian listed above. I have read/understand all included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I understand and agree that all services rendered to me will be charged to me, and I am responsible for timely payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.

  • Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: