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(812) 268-3400
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New Patients Accepted

PATIENT REGISTRATION FORM FOR NEW CHIROPRACTIC PATIENT

Welcome to #TeamWellnessFirst. You've taken the first step and made your appointment. Thank you for choosing to fill out your forms on our website. We will review these with you at your visit. Please use the mouse to guide you to each question. IF AT ANY POINT YOU HIT ENTER BEFORE YOU ARE COMPLETE, THIS SYSTEM WILL EXIT OUT OF THIS FORM. Please hit the back arrow and continue to the bottom of the form. We look forward to seeing you in our office, where your better wellness awaits!

PERSONAL AND DEMOGRAPHIC INFORMATION

CONTACT INFORMATION

We will NOT share your email or contact information with any third party. We will only use this to contact you in relation to your care with our practice.

Employment Information

INSURANCE AND PAYMENT INFORMATION

Please note we will need copied of all insurance cards that apply on your first visit. There is no fee to check your benefits.

If an auto accident, please provide the following:

HOW DID YOU HEAR ABOUT OUR OFFICE? Please fill out all that applies.

CURRENT SYMPTOM #1

CURRENT SYMPTOM #2

If yes, please tell us about it in the following questions. If no, please skip to the end of this section.

PERSONAL INCIDENT HISTORY AND CHIROPRACTIC EXPERIENCE

Please list the last date of the following. You can also say unknown or N/A.

FOR WOMEN

PERSONAL INCIDENT HISTORY

FAMILY HEALTH HISTORY

HEALTH GOALS

SOCIAL HISTORY AND LIFE CHOICES

PAST AND CURRENT HEALTH HISTORY

Check each that applies if you have had it in the past or have been diagnosed with it currently.

Whew! You made it! Thank you for completing this form on our website! We will review it with you at your appointment. We look forward to seeing you in our office and welcoming you in person to #TeamWellnessFirst!

Services

Services
We strive to provide complete care for our patients. Learn more about all the services we provide.
Make An Appointment
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Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.