New Patient Intake Form

2502 N. Johns St, Suite B · Garden City, KS 67846 · (620) 271-0243

Required fields marked * — kept strictly confidential

Patient Information

First Name *Middle InitialLast Name *

Date of Birth *Gender *

Contact Information

Street Address *Apt / Suite

City *State *Zip Code *

Primary Phone *Email Address

Emergency Contact

Full Name *Relationship *Phone Number *

Insurance / Payment

Payment Method *

InsuranceSelf-PayAuto / Workers' Comp

Reason for Visit

Primary Complaint / Chief Concern *

When did this condition begin? *How did it start?

Current Pain Level (0 = No pain · 10 = Worst imaginable) *

0 — None5 — Moderate10 — Severe

What makes it worse?What makes it better?

Does the pain radiate or travel anywhere?

How Did You Hear About Us?

SourceReferring person's name (optional)

HIPAA Notice of Privacy Practices

Your Health Information Rights

Under HIPAA (45 CFR Parts 160 & 164), you have the right to inspect and obtain a copy of your protected health information (PHI), request corrections to your records, request an accounting of disclosures of your PHI, request restrictions on how your PHI is used or disclosed, receive communications about your health information in a confidential manner, and file a complaint with our office or the U.S. Dept. of Health & Human Services if you believe your privacy rights have been violated.

How We Use Your Information

We use your PHI solely for treatment, payment, and healthcare operations. We will not sell or share your information for marketing purposes without your explicit written authorization. A full copy of our Notice of Privacy Practices is available at the front desk or upon request.

By signing below, you acknowledge that you have been offered a copy of our Notice of Privacy Practices and consent to the use and disclosure of your PHI as described above.

Patient Signature — HIPAA Acknowledgement *Date *

If signing on behalf of patient — Relationship / Authority

Typing your name serves as your electronic signature.

Consent to Treatment

I voluntarily consent to chiropractic examination and treatment by the doctors and staff of this practice. I understand that chiropractic care involves manual procedures including spinal and extremity manipulation, soft-tissue therapy, and rehabilitative exercises. I have been given the opportunity to ask questions about my care. I understand that I may withdraw this consent at any time.

Patient Signature — Consent to Treatment *Date *