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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 *

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

Reason for Visit

All fields in this section are optional.

Primary Complaint

Back PainNeck PainHeadachesSciaticaShoulder PainHip PainAuto AccidentSports InjuryPosture IssuesOther

How long have you had this condition?

Pain Level (0 = none, 10 = severe)

Additional notes or questions for Dr. Hornaman

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. *

After submitting, you'll be taken to our calendar to choose your appointment time. Questions? Call us at (814) 438-7242.