New Patient Online Forms
If you are coming to one of our clinics for the first time, please complete the forms below to save time on your first visit. We look forward to serving you!
Pediatric New Patient Online Form (Newborn - 12 Years Old): Download & Print Form
Adolescent New Patient Form (13 - 17 Years Old): Download & Print Form
Adult New Patient Form (18 - 64 Years Old): Download & Print Form
Medicare New Patient Form (65 + Years Old): Download & Print Form
As a patient of the Injury Relief Chiropractic Clinics, you have certain privacy expectations as well as rights and responsibilities. All of the Injury Relief Chiropractic Clinics are fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security rules for health care providers. The confidentiality of your patient records is of paramount concern to us, and you’ll be asked to review information about how we comply with HIPAA rules and sign a form on your first visit.
Before you begin, do you have these handy?
- Driver’s License
- Insurance Card
YOUR PRIVACY, RIGHTS & RESPONSIBILITIES