New Patients

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 *

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 *

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?

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

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. *

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.

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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