Walk-In Chiropractic

Thank you for

scheduling with

Walk-In Chiropractic!

To save time, please fill out this Patient Check-in form honestly and accurately so we can provide the best care.

Acknowledgment: Walk-In Chiropractic does not accept insurance and accepts only cash and credit card as a form of payment for services. Patients must pay for services received on the same day received, before leaving the clinic.

Patient First Name *

Patient Last Name *

Preferred name/nickname

Patient Gender *

Male

Female

Phone *

Email *

Address *

City *

State *

Zip code *

Great! Who can we contact in case of emergency?

Emergency Contact Name *

Emergency Contact Phone *

Your Emergency Contact's Relationship to Patient *

Now, tell us more about patient health and history.

Have you been to a Chiropractor before? *

Yes

No

Who is the "Other" you have seen for this problem? *

What type of treatment or medication was prescribed or performed? *

What is the result? *

Last step! Please review our privacy policy and sign the form.

Notice Of Privacy Policy

Protecting the privacy of your personal health information is important to us. Disclosure of your protected health information without authorization is strictly limited to defined situations that include emergency care, quality assurance activities, public health, research, and law enforcement activities. Any other disclosure for the purposes of treatment, payment or practice operations will be made only after obtaining your consent.

You may request restrictions on your disclosures.
You may inspect and receive copies of your records within 30 days with a request.
You may request to view changes to your records.
In the future, we may contact you for appointment reminders, announcements and to inform you about our practice and its staff.

Notice of Privacy Policy *

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow up with multiple healthcare providers who may be involved in that treatment directly or indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physicians certifications. I have read and understand your Notice of Privacy Practices. A more complete description can be requested. I also understand that I can request, in writing, that you restrict how my personal information is used and/or disclosed.

Consent for Use of Photos and Videos for Marketing Purposes

I hereby give my consent to Walk-In Chiropractic to take photos or videos for record-keeping purposes

I hereby give my consent to Walk-In Chiropractic to use photos or videos, as aforementioned, for marketing purposes. This includes the company's website, social media platforms, newsletters & other marketing materials.

For whom are you filling out this form? *

For myself

For my dependent under the age of 18

Consent Form to be Signed by Parent/Guardian *

I give my consent for my child to receive chiropractic care at Walk-In Chiropractic. I understand the nature of chiropractic treatment, its benefits, and potential risks. I have had the opportunity to ask questions. I agree to allow Walk-In Chiropractic to communicate with me regarding my child's treatment plan, progress, and any other relevant information. I give my consent for my child to receive chiropractic care at Walk-In Chiropractic. I understand the nature of chiropractic treatment, its benefits, and potential risks. I have had the opportunity to ask questions. I agree to allow Walk-In Chiropractic to communicate with me regarding my child's treatment plan, progress, and any other relevant information.