Get Electronic Health Records Intake Form - Price Chiropractic Center

Filling out your Electronic Health Records Intake Form is an essential step in receiving chiropractic care at Price Chiropractic Center. This guide will walk you through the process, ensuring that each section of the form is completed accurately and efficiently.

Follow the steps to complete your intake form online.

1. Press the ‘Get Form’ button to access the form and open it in your preferred online editor.
2. Begin by entering your first and last name in the designated fields at the top of the form. Ensure that the spelling is correct to avoid any confusion in your medical records.
3. Provide your email address in the correct format, ensuring it includes both the username and domain. This is crucial for receiving communications from the clinic.
4. Select your preferred method of communication for patient reminders by circling one option: Email, Phone, or Mail.
5. Fill in your date of birth using the format provided (__/__/____). This information helps verify your identity and is necessary for your medical records.
6. Indicate your gender by circling one option: Male or Female.
7. Write your preferred language in the provided space, ensuring effective communication during your visits.
8. For smoking status, circle one of the options provided: Every Day Smoker, Occasional Smoker, Former Smoker, or Never Smoked. If you're comfortable, you can also include the smoking start date in the optional field.
9. Report your race and ethnicity by circling the appropriate options. Please note that you can choose to decline to answer these questions by selecting the declining option.
10. List any medications you are currently taking, including regularly used over-the-counter medications. Be sure to provide both the medication name and dosage/frequency.
11. If applicable, indicate any medication allergies you have by providing the medication name, type of reaction, and onset date.
12. You may include any additional comments relevant to your health or chiropractic care in the designated section.
13. If you choose, you can decline receipt of your clinical summary after every visit by checking the respective box. Note that these summaries may often be blank due to the nature of chiropractic care.
14. Sign the form to confirm the information is accurate and complete, then add the date of signing.
15. Once all fields are completed, save your changes, download the form, or print it for submission as needed.

Start completing your Electronic Health Records Intake Form online today for a smooth chiropractic experience.