Get Il Chiropractic Center New Patient Form 2021-2025

Completing the IL Chiropractic Center New Patient Form online is a straightforward process designed to gather essential information for your chiropractic care. This guide will help you navigate each section of the form, ensuring a smooth and efficient experience.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the date at the top of the form, and provide your full name in the designated field. Ensure that you include your home phone, cell phone, and email address for contact purposes.
3. Indicate whether you consent to text communication by selecting ‘Yes’ or ‘No.’ If you choose ‘Yes,’ specify your cell phone carrier.
4. Select your gender, and provide your age, date of birth, and social security number. Fill in your mailing address, including city, state, and zip code.
5. Choose your marital status from the options provided and enter the number of children you have.
6. Fill out your occupational details, including your job title, hours worked per week, and your employer's name and business phone number.
7. Provide your partner’s name, their employer, and their business phone number if applicable.
8. Designate an emergency contact and detail their relationship to you along with their phone number and address.
9. Complete the section regarding health insurance by indicating whether you have insurance and providing the company name.
10. If you have received previous chiropractic care, specify that and explain the problem treated, along with the name of the treating doctor and their location.
11. Indicate how you were referred to the clinic and any current injury status related to work or auto incidents.
12. Fill in the person responsible for the account and their contact information.
13. Select your preferred payment method before moving on to additional medical history sections.
14. Answer all subsequent questions regarding your health history, any past problems, and current medications or treatments.
15. Review and complete any additional sections, including the informed consent, cancellation policy, and authorization to release records.
16. Once completed, be sure to sign and date the form to validate your submissions. Finally, save your changes, and download, print, or share the form as needed.

Start filling out your IL Chiropractic Center New Patient Form online today for a seamless onboarding experience.