New Patient Form

Below is our online New Patient Form.

Patient Information Form

Step 1 of 7

Patient Security and Disclosures
Acknowledgements*
- I hereby instruct and direct my insurance company to pay by check made out and mailed to Tuck Chiropractic Clinic.
- I authorize the release of information by any media pertinent to my case to any insurance company, adjuster, or attorney involved in this case, and verification of employment.
- I also authorize the doctor to initiate a complaint to the Insurance Commissioner for any reason on my behalf.
- I understand that I am financially responsible to Tuck Chiropractic Clinic for all charges incurred and not covered by the insurance, workers compensation and any collection, thirty-three and one third per cent (33 1/3%) attorney fees, interest and/or cost accrued in trying to collect this account.
- I understand any balances over 90 days are subject to accrued interest of 1.5 percent per month.
- I acknowledge that this information is true and correct.
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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Start Date	Brand Name	Dosage	Condition

New Patient Form

Patient Information Form

Step 1 of 7

Personal & Contact Information

Insurance Information

Emergency Contact Information

Medical History

Medical History - Surgical Procedures

Medication(s)

X-Ray Information and Consent

Family Medical History

Personal Health

Occupational History

What is your primary reason for visiting Tuck Chiropractic?

Review of Systems: Musculoskeletal and Nervous

Do you have any other pain?

Patient Security and Disclosures