atlanticchiropractic.net offers our patient form(s) online so they can be completed in the convenience of your own home or office. Please fill out one of the forms that most applies to you. If you have any questions, feel free to call Atlantic Chiropractic Associates for assistance.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Download the necessary form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
New Patient Intake
Please print and complete the form below. This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Motor Vehicle Collision Details
Required ONLY if you have been involved in a CAR accident. If you are coming in to be treated for an auto accident, you MUST fill this out.
Work Injury Details
Required ONLY if you have been involved in a WORK injury/accident. If you are coming in to be treated for an injury sustained while on the job, you MUST fill this out.
Re-Evaluation - New Condition
Please download and complete if you are an ESTABLISHED patient and have not been seen in 90+ DAYS or have new symptoms.
Re-Evaluation - Current Condition
Please download and complete if you are CURRENTLY on a treatment plan and are coming in for a progress evaluation of your CURRENT symptoms.
Complete the ABOVE form IF your symptoms are NEW or it has been 90+ DAYS since your last appointment.
Per federal law and our own office policy, here is a copy our HIPPA Notice of Privacy Practices for you to read and review if you so desire.