328 W Howard St

Live Oak, FL 32064 US

(386) 362-2022

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New Patient Form

Welcome to our office!


Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 




About this Patient 

Male
Female
Other
Married
Single
Widow

About the Spouse 

Reason for this Visit

Auto
Fall
Other
Gotten worse
Stayed Constant
Comes and goes
Work
Sleep
Daily Routine
Other activities
Yes
No
No
Yes

Place an X on the image below, where you feel pain, numbness or tingling:

Experience with Chiropractic 

Yes
No
Nerve Pills
Pain Killers (including Aspirins)
Muscle Relaxers
Blood Pressure Medicine
Insulin
Stimulants
Blood Thinners
Tranquilizers

Health Habits

Daily
Moderately
No
Heel lifts
Sole Lifts
Inner Soles
Arch Supports

Health Conditions 


Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.


Severe or Frequent Headaches
Sinus Problems
Dizziness
Cancer
Loss of Sleep
Hepatitis
Pain Between the Shoulders
Frequent Neck Pain
Numbness or Pain in Arms/Legs/Hands
Lower Back Problems
Digestive Problems
Ulcers/Colitis
Heart Attack/Stroke
Thyroid Problems
Kidney Problems
Congenital Heart Detect
Heart Surgery/Pacemaker
High/Low Blood Pressure
Psychiatric Problems
Difficulty Breathing
Rheumatic Fever
Asthma
Arthritis
Alcohol/Drug Abuse
Venereal Disease
HIV/AIDS
Diabetes
Tuberculosis
Shingles
Chemotherapy
Anemia

FOR WOMEN ONLY

Yes
No
Yes
No
Yes
No

Authorization for Care


I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate.

I clearly understand and agree that all the services rendered to me are charged directly to me and that I am personally responsible for all payment. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if I suspend or terminate my care, any fees for professional services rendered to me will become immediately due and payable. I hereby authorize assignment of my insurance rights and benefits (if applicable) directly to the provider of services rendered.

Emergency Contact

My Health Insurance


I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


ABOUT THE INSURED PERSON

Initial Consultation Form 


Constant - 100% of the time
Frequent - 75%
Intermittent - 50%
Occasional - 25%
Minimal (An annoyance but has no effect on activity)
Slight (Tolerable with some impairment to activity)
Moderate (Tolerable with marked impairment of activity)
Severe (Intolerable and cannot perform any activities)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%

Insurance:


We will verify all insurances and your benefits per your agreement with your carrier. After verification the Doctor will give his recommendations and an appropriate plan will be designed for each individual. Please let the front-desk know if you have been in some type of accident or have been injured on the job. This will enable us to give you any and all information necessary to serve you completely and accurately. 

Agreement:


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Thank you for taking the time to fill out this form.

Sign-up using the form below or call us at (386) 362-2022 to make an appointment

Office Hours

Our Regular Schedule

North Florida Chiropractic Center

Monday:

8:30 AM - 12:00 PM

1:30 PM - 5:30 PM

Tuesday:

Closed

Closed

Wednesday:

8:30 AM - 12:00 PM

1:30 PM - 5:30 PM

Thursday:

9:00 AM - 12:00 PM

1:30 PM - 5:30 PM

Friday:

8:30 AM - 12:00 PM

Closed

Saturday:

Closed

Closed

Sunday:

Closed

Closed

Location

Find us on the map

Testimonial

  • "North Florida Chiropractic has the friendliest staff. They are all extremely caring."
    Taylor B. / Live Oak, FL

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