Adult New Patient Form

Patient Registration

Best phone # to reach you during business hours:
Marital Status:
Do you seek help for:

HIPPA Practice's Requirements

This Practice:

a)     Is required be federal law to maintain the privacy of you PHI and to provide you with Privacy Notice detailing the Practice's legal duties and privacy with respect to you PHI

b)     Under the Privacy Rule, may be required be State Law to grant greater access or maintain great restrictions on the use of release of you PHI that which is provided for under federal          law

c)     Is Required to abide by the terms of the Privacy Notice

d)     Reserves the right to change the terms of this Privacy Notice and to make the new Privacy Notice provisions effective for all of you PHI that it maintains

e)     Will distribute any revised Privacy Notice to you prior to implementation

f)      Will not retaliate against you for filing a complaint

Effective Date: 04/14/2003 

Parient Acknowledgment: By subscribing my name below, I acknowledge receipt of my copy of this Notice, and my understanding and agreement to its terms.

Billing Assignment

Injury/Accident Information

Is your condition due to an accident?
Type of Accident:
Have made a report of you accident:

Insurance Information:


Who is responsible for this account?


Who is responsible for this account?

Assignment and Release:

I the undersigned, certify that I (of m dependent) have insurance coverage with the above listed insurance company/companies. I assign directly to Bruce Chiropractic all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

By signing below, I acknowledge that Bruce Chiropractic has informed me that payment for services and supplies may de denied under my health insurance plan, if applicable. I agree that if denied as medically not necessary, referral on file, exceed benefit limits or any other reason, including non-insured, I accept full responsibility to Bruce Chiropractic for service or supplies received

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7: Does the pain symptom radiate?
8. (Select one) How bad is it?
9. (Select one) Pain is present:
10. (Select one) degree of pain (0=none, 10=severe)
11. (Select one) Pain is:
12. Are there any other symptoms related to your primary complaint?



Alcohol Use:
Caffeine Use:


Drug Use:
Exercise Habits


Physical Demands:

Past Medical History (Please list any current or prior health problems):

General health problems:
Addiction or drug abuse problems:
Neurological/Psychological problems:
Spinal/Spinal Cord problems:
Musculoskeletal problems:
Heart problems
Vascular/Circulatory problems
Eye/Ear/Nose/Throat problems:
Breathing/Respiratory problems:
Stomach/Colon/Digestive problems:
Genital/Urinary problems
Endocrine/Diabetic/Hormone problems:
Immune system problems:
Bleeding/Blood problems:
Previous/current infections:
Tumors/Cancer problems
Have you experienced and of the following:
Pain Intensity

In order to properly assess you condition and accurately grade you response to treatment, we must understand how much your neck and/or back problem(s) have affected your ability to manage everyday activities (ADLs). For each section below, please select the one number which most closely describes your condition right now. 

Pain Intensity:
Pain Frequency:
Personal Care (washing, dressing, etc.):
Travel (driving, etc):

Thank you for taking the time to fill out this form.

Our Locations

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Office Hours

Our Regular Schedule

Lancaster (Historic Downtown)


8:00 am-5:00 pm


7:00 am-4:00 pm


8:00 am-5:00 pm


7:00 am-4:00 pm


6:00 am-1:00 pm