New Patient Form

Personal & Contact Information

Which clinic do you plan to visit?*

Legal Name*

First Name Last

Name you prefer to be called by:*

Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

My Home Address is different from my Local Address

Local Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Social Security Number

Gender*

This field is hidden when viewing the form

Gender

Male

Female

Pronouns

Marital Status

Date of Birth*

Race

Ethnicity

Hispanic/Latino

Not Hispanic/Latino

Decline to Answer

Home Phone*

Mobile Phone

Cell Carrier

Email*

How would you prefer to be contacted?*

Cell Phone

Text Message (By checking this box, you agree to receive appointment information and correspondence.)

Home Phone

Work Phone

E-mail

Are you employed?

Yes

No

Employer

Work Phone

Primary Language

Spouses Name (if applicable)

First Last

Spouse's Date of Birth

Insurance Information

Would you like us to file with your health insurance?*

Yes

No

What is your Insurance company? (n/a if not using)*

What is your Insurance ID number? (n/a if not using)*

On the back of your insurance card, what is the provider phone number for benefits and eligibility?

If you have health insurance, who is listed as the primary policy holder?*

I am listed as the primary policy holder.

Someone other than myself.

N/A

Name of Insurance Policy Holder

First Last

Insurance Holder's Date of Birth

Who is responsible for this bill?*

Emergency Contact Information

Emergency Contact*

First Last

Emergency Contact's Phone*

How did you hear about us?

Dr. Referral

Family / Friend / Co-worker

Google

Postcard

Other

Name of referrer, or other?

Has anyone in your household been a patient here before?

Yes

No

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.

CAPTCHA

Patient Information Form

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

Locations

Services