chiropractic patient intake form template

Chiropractic Patient Registration and Health History

Instructions for Use

• Complete all sections of this form accurately, ensuring that all medical history and insurance information is current as of the date of signing.
• Provide a valid government-issued photo identification and your current insurance card to the front desk staff upon submission.
• Review the Consent for Treatment and Privacy Notice sections carefully before signing, as these establish the legal framework for your care.

Parties & Definitions

This document is entered into by and between [Practice Name], hereafter referred to as the "Clinic," and [Patient Full Legal Name], hereafter referred to as the "Patient," residing at [Patient Home Address].

Operative Clauses

1. Patient Information:

   • Date of Birth: [__________]
   • Phone: [__________]
   • Email: [__________]
   • Emergency Contact Name: [__________]
   • Emergency Contact Phone: [__________]

2. Chief Complaint:

   • Primary reason for visit: [__________]
   • Date symptoms began: [__________]
   • Pain intensity (1-10): [__________]
   • Is this condition related to: [ ] Auto Accident [ ] Work Injury [ ] Other: [__________]

3. Medical History:

   • List current medications: [__________]
   • List known allergies: [__________]
   • Surgical history: [__________]
   • Check all that apply: [ ] Hypertension [ ] Diabetes [ ] Osteoporosis [ ] Cancer [ ] Pacemaker [ ] Pregnant

4. Consent for Chiropractic Care: The Patient acknowledges that chiropractic care involves the adjustment of the spine and other joints. The Patient understands that while chiropractic care is generally safe, there are rare risks associated with such procedures, including but not limited to fractures, disc injuries, or strokes. The Patient hereby consents to examination and treatment by the Clinic.

5. Financial Responsibility and Insurance: The Patient agrees to be financially responsible for all charges incurred, regardless of insurance coverage. The Patient authorizes the release of medical records to insurance carriers for billing purposes and assigns all insurance benefits directly to the Clinic.

6. Privacy Practices: The Clinic maintains a Notice of Privacy Practices in compliance with HIPAA. The Patient acknowledges they have been offered the opportunity to review said notice.

7. Cancellation Policy: The Patient agrees to provide at least [] hours' notice for any appointment cancellation. Failure to provide such notice may result in a fee of $[].

Signature & Acknowledgment

By signing below, I certify that the information provided is true and accurate to the best of my knowledge, and I agree to the terms outlined above.

Signature: __________ Printed Name: [] Title: [Patient or Legal Guardian] Date: []

DISCLAIMER: This document is a general framework intended for informational purposes only. It does not constitute legal advice. You must consult with qualified legal counsel to ensure compliance with state-specific healthcare regulations, HIPAA requirements, and local professional board standards.