Patient Forms

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

A. New Patient

       1. Financial Policy - revised 02-24-2011.doc [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]

       6. System Survey Form [PDF]

B. Insurance Verification

       7. E-Z Patient Insurance Verification [PDF]

C. Update

       8. Clinical History Report [PDF]

D. Areas of Complaint

       9. Headache Disability Index [PDF]

     10. Neck Pain - Pain Scale [PDF]

     11. Back Pain - Pain Scale [PDF]

     12. Knee/Patello - Femoral Questionnaire [PDF]

     13. Carpal Tunnel Syndrome Questionnaire [PDF]

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

E. Progress Exam

     15. Progress Examination Questionnaire [PDF]

F. Medicare

     16. About Medicare Coverage [PDF]

G. Miscellaneous

     17. 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.

     18. 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.

Fairfield Spine Center
1600 Sheridan Drive, Lancaster, OH | (740) 687-5002