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New Chiropractic Patient

Access new patient information and forms

Your First Chiropractic Visit

Filling out the New Patient forms before you get to the office can save you time on your first visit. Please fill out the required forms found below. You can either download the forms to print, fill out, and turn in to the office assistant upon arriving at the office, or you can fill out the online form and submit it. If you are unable to complete the paper work prior to your visit, please arrive approximately 15 minutes early, so that sufficient time is available to fill out the necessary paperwork.

If you have an insurance provider, bring your card to your first appointment. If you have digital or film x-rays that were taken within the past 30 days, please bring them with you. Upon examination further x-rays may be required.

Print Form to Fill Out and Bring With You to the Office:

Download Form

OR
Fill Out The Form and Submit Online:
  • General Information


  • Date Format: MM slash DD slash YYYY


  • Date Format: MM slash DD slash YYYY

  • Insurance Information


  • Date Format: MM slash DD slash YYYY


  • Date Format: MM slash DD slash YYYY

  • Release and Assignment




  • Patient History/Examination Form

    Complete ALL Questions Below

  • Mechanism of Injury




































  • Patient History

    Please check all present symptoms

































































































































  • Policies

    1. All first visit charges are payable when services are rendered.

    2. The fee paid for treatment x-rays is for analysis only. The film itself is the property of this office. Once films are used for treatment purposes, they cannot be released. Copies can be made if necessary.

  • I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself. Furthermore, I understand that West Cary Wellness Center will prepare any necessary reports and forms to assist in making collections from the insurance company and that any amount authorized to be paid directly to West Cary Wellness will be credited to my account upon receipt. However, I clearly understand and agree that all my services are charged directly to me and that I am responsible for payment.

    I also understand that if I suspend or terminate my care at this office, any outstanding charges for professional services rendered me will be immediately due and payable. I agree that I will be responsible for all attorney and legal fees if legal action becomes necessary to collect on this account. If an account balance remains unpaid for three months or longer, a monthly interest fee of 2% will apply to the account balance. I authorize West Cary Wellness to obtain a credit report if deemed necessary.



  • Date Format: MM slash DD slash YYYY


  • Patient Policy Notice

  • Health History of Family Members

    The reason for this form is to assist the doctor by providing past health history information for their review.

    Please check all of the people in your family who have experienced the following conditions: