Patient Forms

1.  Chiropractic New Patient Health History

This outlines your health history and current state of health. We also encourage you to write down any questions you have so that we can answer them during your appointment. We also highly recommend that all new patients download and complete this Insurance Benefits Worksheet. Choose the form based on the patient’s age:

• Adults and Children older than 6 years
• Children Ages 6 and Under

2.  Patient Reactivation

If you are a returning patient but haven’t been to our office within the past 3 months, we will need to collect more recent health information. Please choose the appropriate form based on how long it’s been since your last visit (if you’re unsure, please don’t hesitate to call us at 715-355-4224).

• Your last visit was between 3 months and 1 year ago
• Your last visit was more than 1 year ago

 

3.  Insurance Benefits Worksheet – Recommended

This worksheet helps you to understand your insurance coverage by outlining the questions you should ask your insurance provider. It is your responsibility to verify your coverage and understand what portion of your care you will be required to pay out of pocket. We strongly recommend that you bring this completed form with you to your first appointment.

• Download Form

 

4.  Medical Records Request

To transfer medical records between our office and another provider.

• Download Form

 

5.  Workers’ Compensation

If your visit was due to an injury that happened at work, please use this form. It is required for all workers’ compensation claims.

• Download Form

 

6.  Auto Accident History

If your visit is due to an injury caused by an auto accident, please use this form. It is required for all auto accident claims.

• Download Form

 

7.  Personal Injury Supplement

Our staff will let you know if this form is required as a supplement to Form #1 (Patient Health History).

• Download Form

 

8. Functional Medicine Forms

NEW PATIENTS: completed forms are required before you schedule your first consultation. You will find the Functional Medicine New Patient forms here. STRESS ASSESSMENT: Only complete this form if you are asked to by the doctor.

• Download Form

 

9. HIPAA Release

The HIPAA (Health Insurance Portability and Accountability Act) form is a document used to authorize the release of your protected health information (PHI) to specific individuals who are involved in your care. We cannot share appointment, diagnosis, treatment, or payment information with anyone unless you have designated them on this form.  This form must be submitted in person by the patient.

• Download Form