New Patient FormToday's Date* Name First Last Date of Birth* Age*Marital Status*SingleMarriedWidowedDivorcedSpouse's NameAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Cell Phone*Work PhoneEmail* EmployerOccupationEmergency Contact*Relationshiop*Phone*How did you hear about us?CoworkerOnlineReferralReferred By:Have you had Chiropractic care before?*YesNoDr's Name:*Number of ChildrenSymptomsReason for Visit:*When did you first notice the symptoms?*Is the condition getting progressively worse?*YesNoWhere specifically is (are) the problem(s) located?*Which activities are difficult to perform? Sitting Standing Walking Bending Lying Down OtherPlease Explain:Type of Pain: Sharp Dull Throbbing Numbness Aching Shooting Burning Tingling Cramps Stiffness Swelling OtherPlease Explain:Rate the severity of your pain (1 - mild pain or discomfort, 10 - severe pain)*Please enter a value between 1 and 10.Is the pain constant or does it come and go?What treatment have you already received for your condition? Medication Surgery PT OtherPlease Explain:Please list all current medicationsAllergiesDaily HabitsWhat type of exercise do you perform on a daily basis?*NoneModerateHeavyWhat do your daily work habits include? Sitting Standing Heavy Labor Light Labor Computer WorkDo you smoke?*YesNoHow much per day?*How much liquor do you consume on a weekly basis?*AuthorizationI certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the chiropractor to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such chiropractic care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the chiropractor of chiropractic group insurance benefits otherwise payable to me. I understand that my chiropractic insurance carrier may pay less than the actual bill for service. I agree to be responsible for payment of all services rendered on my or my dependents behalf.Signature of Patient (or parent if a minor)*Date* Informed Consent to Chiropractic CarePatient Name*Please discuss any questions or concerns with the doctor before signing this consent.I hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, include various mode of physical and diagnostic x• rays by the doctor of chiropractic name above.I have had the opportunity to discuss with the doctor and/or with other office or clinic personnel the purpose and benefits of the chiropractic adjustments and other treatments outlined below. Alternative to treatment have been reviewed.Though chiropractic adjustments and treatments are usually beneficial and seldom cause any problem, I understand and am informed that there are some risks to treatment. Risks include, but are not limited to, fractures, disc injuries, strokes, dislocations and sprains.I understand that I will be receiving the following treatment: Chiropractic Manipulative Treatment, Physical Therapy Modalities and Stretching/Strengthening Exercises.I understand that chiropractic is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the chiropractic treatment that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.Signature of patient, parent, guardian or personal representative*Date* Cancellation PolicyShell Chiropractic is happy to provide massage therapy as part of your treatment. We require that all patients must call two (2) hours prior to your scheduled appointment time to cancel. If you do not, you will be billed $35 .00, due on your next visit. The fee is to insure that our facility maintains quality therapists to assist us in meeting your health needs. Please keep in mind that our therapists do not get paid if you do not show up. We understand emergencies occur and for those special circumstances, you will not be billed.Thank You for your cooperationI have read and agree to the policy. I also understand that I may be billed $35.00 for any appointments that I do not call two (2) hour prior to cancel. Signature*Date* This iframe contains the logic required to handle Ajax powered Gravity Forms.