New Patient Forms

Thank you for choosing Allen Chiropractic Care!

Please complete the attached forms and be sure to bring them with you the day of your appointment or, if you prefer, complete and return via fax (276-466-2214).

These forms are designed to allow you to print them and complete them by hand.

Please come to your appointment prepared with the following items:

• Completed Registration Paperwork
• Insurance Card (s) or Proof of Insurance
• Photo Identification
• All medical records pertaining to the body part for which you are being evaluated (MRI, x-ray, clinic notes, etc).
• A list of all medications that you are currently taking

Allen Chiropractic Care

• Information
• Insurance
• Disclosure of Medical Information
• Financial Policy
• Acknowledgement of Receipt of Notice
• Health Insurance Election
• Release of Medical Records
• Notice of Privacy Practices
• Update Patient Information
• Pain and Problem Questionnaire
  
• HIPAA Cassie - [email protected] or Rhonda - [email protected]