The Lancaster Chiropractor to see - Chiropractor Lancaster

Patient Forms

We offer our paperwork on line so you can complete it in the convenience of your own home. Here are the essential forms.

A. New Patient

       1. Our Financial Policy [PDF]

       2. Application for Care - Personal History [PDF]

       3. Application for Care - Consultation [PDF]

       4. Acknowledgement of Receipt of Notice of Privacy Practices [PDF]

       5. Fear Avoidance Beliefs Questionnaire [PDF]

B. Insurance Verification

       6. E-Z Patient Insurance Verification [PDF]

C. Update

       7. Clinical History Report [PDF]

D. Areas of Complaint

       8. Headache Disability Index [PDF]

       9. Neck Pain - Pain Scale [PDF]

     10. Back Pain - Pain Scale [PDF]

     11. Knee/Patello - Femoral Questionnaire [PDF]

     12. Carpal Tunnel Syndrome Questionnaire [PDF]

     13. Shoulder Injury Self-Assessment of Function [PDF]

E. Progress Exam

     14. Progress Examination Questionnaire [PDF]

F. Medicare

     15. About Medicare Coverage [PDF]

G. Miscellaneous

     16. Website Membership Enrollment Form 
           Receive complimentary membership to our Members Only section of
           our website. Fill out the form below and return to our office.

     17. Exercise Questionnaire

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Each form is a PDF document file.  If you do not already have AdobeReader® installed on your computer, click the Adobe® image to download for free.