Forms for New Patients
Please Print & Fill Out Our Forms Before Your First Visit
For your convenience, we have attached the forms you will be asked to complete and sign when you arrive for your first appointment. Please print these forms and complete them in advance. Doing so will save time and paperwork for you on the day of your appointment.
The first form is the Patient Intake Form, this form will need to be completed, signed and dated.
The second form is Patient Health Questionaire (PHQ) Form , this form needs to be completed, signed and dated.
The third form is the 3 Metabolic Assessment Form, this form needs to be completed and dated. This form is only if you are seeing the doctor for a nutrition visit.
The two forms below are both for HIPAA and need to be filled out.
- Acknowledgment of Receipt of HIPAA Privacy Notice - requires signature and must be dated from all patients.
- Informed Consent for Chiropractic Treatment - requires signature and must be dated from all patients.
Complete HIPAA document - This is the complete HIPAA document for reference. You do not need to print this out.
If you have questions about the forms, leave the areas in question blank. We will go over the forms with you in detail when you arrive for your appointment. For your privacy, we ask that you do not complete these forms on-line.
All Shungite Products Discounted 20% in November
We have a great selection of Shungite items on sale this month at Healing River Chiropractic. If you use electronic products in your daily life (and who doesn’t) then you are being exposed to large amounts of EMFs. Find out on our website why those are bad for your health and about the EMF blocking ability of Shungite.