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Address 658 Harleysville Pike #110, Harleysville, PA 19438 Have Any Questions? (215) 256-8006 Schedule An Appointment

New patient forms

Online Patient Intake Form

Please complete this secure intake before your first visit. Your answers help our team understand your concerns, health history, and goals before your evaluation.

Step 1 of 5 Patient, Insurance and Referral Information

Step 1

Patient, Insurance and Referral Information

Complete your contact, insurance, visit-type, and referral information.

Address
Emergency Contact
Payment and Insurance
Do you have health insurance?
Insurance card
Please bring your insurance card and photo ID to your first visit so our team can verify your coverage.
Visit Type
Is today's problem related to any of the following?
Referral Information
How did you hear about us?

Step 2

Current Symptoms

Describe what brought you to the office.

Symptom Pattern
How often do you experience your symptoms?
How are your symptoms changing?
Pain Description
Select all that apply
Pain Rating
Rate your problem from 0 to 10

Step 3

Health History

Select any conditions that apply now or occurred in the past.

Currently Present
Experienced in the Past

Step 4

Medications, Previous Care, Work and Lifestyle

Tell us about medications, prior care, and the demands of your daily routine.

Hospitalization and Prior Chiropractic Care
Have you ever been hospitalized?
Have you seen a chiropractor before?
What were the results?
Have you had significant trauma?
Work and Lifestyle
Overall Health and Exercise
How would you rate your overall health?
What type of exercise do you do?
Work Activities

Step 5

Review and Authorization

Review the information above and complete the acknowledgments below.

Information Accuracy

By submitting this form, I attest that the information I provided is true and accurate to the best of my knowledge.

Financial Responsibility

“Yes,” my personal identifying information will not be disclosed. I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. I understand that this office will prepare any necessary reports and forms to assist me in making collection from the insurance company and that any amount authorized to be paid directly to this office will be credited to my account on receipt. However, I clearly understand that I am responsible for the payment of all services rendered to me if my insurance company, for whatever reason, does not pay for services rendered to me. I also understand that if I terminate my care, any fees for professional services rendered to me will become due and payable.

Please complete the required fields on this step before continuing.
✓

Thank You — Your Intake Was Submitted

Your information has been sent to Family Chiropractic of Lederach. Our team will review it and contact you if anything else is needed before your visit.