First-Visit Information

First-Visit Information

We need to learn some things about you in order to provide you with extraordinary care!
Please share your full name:*
First Name
Last Name
Please share your full name:*

First NameLast Name
Please enter your email address:*
example@example.com
Please enter your mailing address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

The following information is required by insurance companies for appropriate documentation of claims. Thanks for understanding!
Your biological sex at birth:*

MaleFemale
Your date of birth:*

MonthDayYear
Date
Your social security number:*
Your marital status:

SingleMarriedDivorcedWidowedOther

Do we have permission to send mail/email to the address above?

YesNo
Is your health condition related to an auto accident or work accident?

YesNo
If so, what was the date of the accident or injury?

MonthDayYear
Date
Do you have insurance that you would like to use for a portion of your care?
Please upload a picture of the front and back of your insurance card.

Browse Files

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What health challenges or concerns brought you to us?
What other health challenges would you like us to discuss with you?
Have you been admitted to the hospital for this condition? If so, please share the hospital, date(s) and procedures received:

Have you even been under chiropractic care?

YesNo
Who was the last chiropractor you saw and when was your last adjustment?
Please list the name of your primary medical doctor (if any):
On approximately what date did you last see your medical doctor?

MonthDayYear
Date
Have you had any MRI, X-rays or CAT scans for this condition? If so, please share dates and procedures received:
Please list all medications that you are currently taking, including over-the-counter medications, supplements, and vitamins:
Please list all vaccinations that you have received in the last 5 years.
Do you have allergies to medication? If yes, please indicate the allergy and reaction:
Please share the dates and types of all surgeries you may have received:

Do you use tobacco?
Please share your number of regular alcoholic drinks consumed per day:
How many 8-ounce cups of coffee do you consume per day?
How many 12-ounce portions of soda do you consume per day (diet and full-sugar)?
How many 8-ounce glasses of water do you drink per day?
Please describe your level of exercise:

Emergency contact person:
First Name
Last Name
Emergency contact person:

First NameLast Name
What is the relation of the person above to you?
Emergency contact cell phone number:

Area CodePhone Number
Most of our practice members are referred. Who can we thank for sending you? (Or where did you hear about us?)
THANK YOU for completing this form!

You will be asked for a copy of your driver's license and insurance information at your appointment time. Please make sure that you have this information available.

We're excited to get to know you and to guide you to optimal health!
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