Form Testing - Tuck Chiropractic

Name*

First Last

Birthdate*

Best Phone to Contact You*

Email*

Which clinic is most convenient for you?*

Are you a new or returning patient?*

New Patient
Returning Patient

Which day of the week do you prefer?

First Available Appointment
Monday
Tuesday
Wednesday
Thursday
Friday

Which time of the day do you prefer?

Early AM
Late AM
Early PM
Late PM

What is your reason for seeing a doctor?*

HIPAA Compliance Acknowledgement of Receipt*

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notices of our privacy practice. We protect your health information and what rights you have regarding it, if we need to disclose your health information outside of our office for these reasons we will ask for your written permission. If you would like a copy of this policy please feel free to email or call our office and we would be happy to provide it to you.

I acknowledge that I have reviewed this policy and that I was offered a copy of the “Notice of Privacy Practices”.

Disclaimer*

Please note, submitting this form does not substitute for an office consultation. By submitting this form, no Doctor-Patient relationship is formed with Tuck Chiropractic Clinic. We will require you to come in for an in-office consultation. This will ensure that any care we provide is customized for each patient. It is important to remember that any information received through this website and email cannot be guaranteed to be confidential because of the possibility that a third party could intercept the message. Of course, once our office receives the information, it will be maintained in a confidential manner.

I have read and understand the disclaimers of this web site.

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