New Patient Health Record

    Personal and Insurance Information
    all entries with a red * are required answers

    Current Health Conditions

    Past Health History

    Below is a list of diseases which may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as these problems can affect your overall course of care.
    Most patients that come to our office have one or two objectives in mind concerning their health care.  Some patients come for symptomatic relief of pain or discomfort (Relief Care).  Others are interested in having the cause of the problem as well as the symptoms corrected and relieved (Corrective Care).  Your doctor will weigh your needs and desires when recommending your treatment program. 
    Please check the type of care desired so that we may be guided by your wishes whenever possible.

    Final Step- agreements and E-Signature

    With my typing of my name below, I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself.  Furthermore, I understand that the Doctor's 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 the Doctor's Office will be credited to my account on receipt.  However, I clearly understand and agree that all services rendered to me are charge directly to me and that I am personally responsible for payment.  I also understand that if I suspend or terminate any fees for professional services rendered to me will be immediately due and payable.  


    I hereby authorize the Doctor to treat my condition as he or she deems appropriate.  It is understood and agreed the amount to be paid the Doctor, for X-Rays, is for examination only and the X-Ray negatives will remain the property of this office, being on file where they may be seen at any time while a patient of this office.  The patient also agrees that he/she is responsible for all bills incurred at this office. 

    Consent to Treat Minor- Please sign the consent form below if the patient is under 18
    By typing my name below, I authorize Shipman Chiropractic to treat the minor listed above. I verify that I am a legal guardian or representative of the minor listed above.