New Patient

New Patient Form


Welcome! If you are planning your first visit to Concierge Chiropractic of Texas, we look forward to meeting you! To save time on your first visit, we encourage you to download, print, and fill out our new patient forms below.

If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form, print it out, and fill in the required information.

  • Complete your forms and bring them in with you to your appointment.
    ​​​​​​​

Download New Patient Form

New Patient Intake Form

First Name*
Middle Initial*
Last Name*
Address*
City*
State*
Zip Code*
Home Phone
Cell Phone
Email
Date of Birth*
Sex*
Marital Status*
Children*
Ages
Emplyment Status:

Emergency Contact

Contact Name*
Reletaionship to Patient*
Contact Phone*
Would you like us to verify your health insurance coverage?*
How did you hear about our office?
Do you have primary complaint?
When and how did it begin?
What it makes better?
Worse?
(Women only) Are you pregnant?
If you are experiencing pain, is it:
(Mark all that apply)
Does the pain:
How often does thta pain occur?
If the pain travels, where does it go?
How would you rate your pain?
(0 = no pain, 10 = worst pain possible):
Since the onset, has the complaint?
Is this keeping you from...
How would you rate you HEALTH right now?
(0 = Unhealthy, 10 = Optimum Health)
Have you been under chiropractic care? If so, when?
Mark the conditions that you are currently or have recently been diagnosed with.
​​​​​​​
MUSCULOSKELETAL conditions:
CARDIOVASCULAR conditions:
GASTRO-INTESTINAL conditions:
URINARY/REPRODUCTIVE conditions:
NERVOUS SYSTEM conditions:
GENERAL conditions:
List ALL current medications (include all-over-the-counter, supplements, and hebs):
List any accidents or traumas, when they happened, and what was injured:
List any major surgeries:

Name of primary Care Physician and Approx. Date of Last Visit:

Have you been treated for any conditions in the last year?

If yes, please explain

Please include any additional information, concerns, or questions you would like to add:

The statement made as to the questions asked on this form are accurate to the best of my knowledge and I agree to allow this office to examine me for further evaluation. I understand that any and all information on this form in the file will remain confidential to myself, the doctor, and any other authorized personnel. I authorize payment of insurance benefits directly to the chiropractor or chiropractic office.

Name*

Date*

Helpful Articles
ArleeVa123! none By Appointment Only chiropractor # # #