Existing Patients

Patient Details

Please complete your details before your visit. All information is kept strictly confidential in accordance with HIPAA. If you haven't been seen in over 3 years, please use the new patient intake instead.

Personal Information

First Name *

Last Name *

Date of Birth *

Sex at Birth *

Phone Number *

Email Address *

By submitting this form, you agree to receive text messages from Hornaman Chiropractic Center at the number above: appointment confirmations and a one-time request to review us on Google. Message frequency varies. Message and data rates may apply. Reply STOP to opt out, or call (814) 438-7242 for help. We do not share mobile numbers with third parties for marketing. See our Terms and Privacy Policy.

Home Address

Street Address *

City *

State *

ZIP Code *

Emergency Contact

Full Name

Relationship

Phone Number

Insurance

Has your insurance changed since your last visit? *

No — use insurance on fileYes — my insurance has changed

HIPAA Consent & Authorization

By submitting this form, I authorize Hornaman Chiropractic Center to use and disclose my protected health information for treatment, payment, and healthcare operations as described in the HIPAA Notice of Privacy Practices. I understand I have the right to revoke this authorization in writing at any time.

I have read and agree to the HIPAA Privacy Practices and authorize Hornaman Chiropractic Center to use my information for treatment purposes. *

Choose an Appointment Time *

All times are Eastern Time. Same-day appointments can't be booked online — please call (814) 438-7242. Online requests need at least 12 hours' notice and can be made up to 60 days ahead.

Loading available times…

Your appointment is confirmed once our office approves it; we'll let you know by email or text. Questions? Call us at (814) 438-7242.