Patient Forms
Complete forms before your visit to save time and ensure a smooth check-in
Download Forms
Click below to download each form as a PDF. Print and complete them before your appointment.
Complete at Home
Fill out forms at your convenience with accurate information. Bring them to your appointment.
Faster Check-In
Completed forms mean less time in the waiting room and more time with your doctor.
New Patient Forms
New Patient Registration
Required for all first-time patients. Includes personal information, medical history, and emergency contact.
Medical History Form
Comprehensive medical history including past illnesses, surgeries, and family history.
HIPAA Privacy Notice
Notice of privacy practices and how your medical information may be used and disclosed.
Consent to Treat
Authorization for treatment and acknowledgment of risks and benefits.
Insurance & Billing
Insurance Information Form
Primary and secondary insurance information for billing purposes.
Authorization to Release Medical Records
Permission for us to release your medical records to other providers.
Request for Records
Form to request copies of your medical records from our office.
Pain Assessment
Pain Questionnaire
Detailed assessment of your pain including location, intensity, and impact on daily life.
Oswestry Disability Index
Functional assessment specifically for back pain patients.
Neck Disability Index
Functional assessment specifically for neck pain patients.
Pain Diagram
Body map to indicate the location and type of pain you experience.
Post-Procedure
Post-Procedure Instructions
General instructions for after your procedure. Specific instructions will be provided based on your treatment.
Post-Procedure Symptom Log
Track your recovery symptoms and progress after treatment.
Electronic Forms Available
Complete forms securely online through our patient portal. Your information is encrypted and HIPAA compliant.
Benefits of electronic forms:
- ✓ No printing needed
- ✓ Auto-fill existing info
- ✓ Instant submission
- ✓ Secure & encrypted
What to Bring to Your Appointment
- ✓Photo ID
Valid driver's license, passport, or state ID
- ✓Insurance Card
Primary and secondary insurance cards if applicable
- ✓Completed Forms
All new patient forms if not completed electronically
- ✓Medical Records
Any relevant imaging (X-rays, MRIs, CT scans), lab results, or records from other providers
- ✓Medication List
Current medications including dosages, or bring the bottles
- ✓Method of Payment
Credit card, check, or cash for copays and deductibles
Questions About Forms?
Our staff can help answer questions about required documentation
Call 917-524-7246