New patients

Fill Out Your New Patient Form Online

Answer the questions below, then download or print your completed PDF. Bring it with you or email it to the office before your visit.

Your answers stay in your browser — nothing is sent or stored until you download the PDF and send it to us yourself. Prefer paper? Download the printable form.

Patient Information

Your cell number will be used for appointment reminder texts.

Full name

Preferred name / nickname

Date of birth

Sex

Male

Female

Status

Minor

Single

Married

Other

Phone #1 (cell preferred)

Phone #2

Street address

City

State

ZIP code

Employer / school

Occupation

Emergency contact name

Emergency contact phone

Relationship

Whom may we thank for referring you?

Insurance & Financial

Is a parent or guardian financially responsible?

Yes

Guardian name & relationship

Primary insurance

Secondary insurance

Privacy & Communications

List anyone we may share your health information with.

Primary healthcare provider

Other person & relationship

Mark Where It Hurts

Tap any area on the figure — front or back — to mark it as a place that hurts or bothers you. Tap again to remove it. You can also use the list below.

Marked areas

None marked yet.

Acknowledgements & Consent

Assignment and release: I assign insurance benefits directly to the doctor and understand I am financially responsible for all charges, whether or not covered by insurance.

Privacy practices: Total Wellness Chiropractic & Holistic Care has made me aware of their HIPAA privacy practices and I may request a copy of the Notice of Privacy Practices at any time.

Consent to care: I request and consent to chiropractic adjustments, muscle therapies, and other usual and customary procedures recommended by the doctors, and I understand the risks involved.

Type patient / guardian name as signature

Dated automatically when you download your PDF.

Email It In

Attach the downloaded PDF to your email, or bring it to your visit. To schedule, call (208) 452-7582.