New Patient Intake Form

Please complete this form before your first visit. All information is kept strictly confidential in accordance with HIPAA. If you have been seen by Dr. Hornaman within the last 3 years, please use the existing patient form 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 *

Insurance Information

Not sure if we accept your insurance? View accepted insurances →

Payment Type *

InsuranceSelf-PayMedicare

Insurance Provider

Policy / Member ID

Group Number

Insurance Phone Number

Name of Insured (if different from patient)

Medical History

Do you have any of the following conditions?

OsteoporosisBlood clotting disorderRecent surgery (within 6 months)Cancer / tumor historySpinal cord injuryRheumatoid arthritisNone of the above

Current medications (list any that may affect treatment, e.g. blood thinners)

Have you had any recent X-rays, MRI, or CT scans related to your current condition?

Yes No

Emergency Contact

Full Name

Relationship

Phone Number

Reason for Visit

Primary Complaint

Back PainNeck PainHeadachesSciaticaShoulder PainHip PainAuto AccidentSports InjuryPosture IssuesOther

How long have you had this condition?

Pain Level (0 = none, 10 = severe)

Have you had chiropractic care before?

Yes No

Additional notes or questions for Dr. Hornaman

One More Thing

How did you hear about us?

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