Digital Forms

Core Chiropractic New Patient Intake
Patient Information
Gender
Have you seen a Chiropractor before?
Emergency Contact
Primary Insurance Information
I certify that I, and/or my dependent(s) have insurance coverage with (Insurance company) _______ and assign directly to Core Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above named clinic may use my health information and may disclose such information to the above named insurance company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signatures
What is the reason for your visit today?
What type of pain(s) are you experiencing?
Is your condition due to an accident?
Type of accident
Are you pregnant?
Mark your areas of concern
Check all symptoms you have ever had, even if they do not seem related to your current problems
Do you have any of the following chronic health problems?
Injuries/Surgeries you have had

Thank you for taking the time to fill out this form.

Location

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HOURS OF OPERATION

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 6:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 6:00 pm

Friday

Massages Available by Appointment Only

Saturday

Massages Available by Appointment Only

Sunday

Closed

Monday
9:00 am - 6:00 pm
Tuesday
9:00 am - 6:00 pm
Wednesday
9:00 am - 6:00 pm
Thursday
9:00 am - 6:00 pm
Friday
Massages Available by Appointment Only
Saturday
Massages Available by Appointment Only
Sunday
Closed