New Patient Form

Date: 09/14/2025

Name(Required)

First Middle Last Suffix

Nick Name

Birth Date(Required)

SSN(Required)

Gender(Required)

Male

Female

Unspecified

Home Address

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Email(Required)

Marital Status

Employment Status

Name of Employer

Employer Phone

Employer Address

Street Address Address Line 2 City State ZIP Code

Emergency Contact(Required)

First Last

Relationship(Required)

Phone(Required)

Referred By

First Last

Security/Verification Question

(Choose one question you wish to answer)

What is the name of your favorite pet?

What was the make of your first car?

In what city were you born?

What is your mother's maiden name?

What high school did you attend?

When is your anniversary?

Answer to Security Question:

Medications (including dosage if known)

(Click the "plus" icon to add additional medications)

Medication

Dosage

Allergies

(Click the "plus" icon to add additional medications)

Briefly list your health history

Have you been diagnosed with hypertension?(Required)

Yes

No

Have you been diagnosed with diabetes?(Required)

Yes

No

Consent

I have read and understand how my Patient Health Information will be used and I agree to these policies and procedures.

We want you to know how your Patient Health Information (PHI) is going to be used at Coon Rapids Chiropractic Office and your rights concerning those records. Before we will begin any health care operations we must require you to read and sign this consent form stating that you understand and agree with how your records will be used. If you would like to have a more detailed account of our policies and procedures concerning the privacy of your PHI we encourage you to read the HIPAA Notice that is available to you at the front desk before signing this consent.

The patient understands and agrees to allow this chiropractic office to use their PHI for the purpose of treatment, payment, healthcare operations, and coordination of care. As an example, the patient agrees to allow this chiropractic office to submit requested PHI to the Health Insurance company(s) provided to us by the patient for the purpose of payment.

The patient has the right to examine and obtain a copy of his or her own health records at any time and request corrections. The patient may request to know what disclosures have been made and submit in writing any further restrictions on the use of their PHI. Our office is not obligated to agree with those restrictions.

A patient's written consent needs only to be obtained one time for all subsequent care given to the patient in this office.

The patient may provide a written request to revoke consent at any time during care. This would not affect the use of those records for the care given prior to the written request to revoke consent but would apply to any care given after the request has been presented.

For your security and right to privacy, all staff has been trained in the area of patient record privacy and a privacy official has been designated to enforce those procedures in our office. We have taken all precautions that are known by this office to assure that your records are not readily available to those who do not need them.

Patients have the right to file a formal complaint with our privacy official about any possible violations of these policies and procedures.

If the patient refuses to sign this consent for the purpose of treatment, payment and health care options, the chiropractic physician has the right to refuse to give care.

Printed Name

Patient Signature

Date: 09/14/2025

Name

This field is for validation purposes and should be left unchanged.

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