New Patient Center — In Motion Chiropractic

PATIENT INFORMATION

Email

Martial Status

Number of Children

Who is responsible for your bill?

EMPLOYMENT INFORMATION

Employer

Occupation

EMERGENCY CONTACT

Name

Relationship

CURRENT HEALTH CONDITION

Chief Complaint

When did the condition begin?

What have you tried to make it feel better?

What makes the pain worse?

Does the pain travel up or down in your body?

Rate your pain

Is your pain worse in the morning, noon or night?

MEDICATION, HERBS, SUPPLEMENTS

Name

Why do you take this Medications, Herbs or Supplement?

Name

Why do you take this Medications, Herbs or Supplement?

Name

Why do you take this Medications, Herbs or Supplement?

Any other Medications, Herbs or Supplements?

LIFESTYLE

Height

Weight

Age

Allergies

Describe your diet

Types of exercise

Hours per week

What are you training for?

Alcohol per week

Average sleep time

Current stress level

PAST HEALTH HISTORY

Please report any past health conditions that may affect a proper diagnosis.

If yes, please explain

Name of Doctor

Review of Systems

(check all that apply)

When was your last period?

Consent for Treatment and Insurance Authorization

I hereby authorize the release of information to my insurance company concerning the charges and treatment provided to me by the doctor of chiropractic at In Motion Sports and Family Chiropractic. I assign any insurance benefits due to me to In Motion Sports and Family Chiropractic for services rendered. I understand that payment is due at the time services are provided, including my deductible, co-payment, coinsurance, or any balance not paid by my insurance company (excluding contractual allowances). ⚠️ IMPORTANT: Most insurance plans DO NOT cover 100% of each visit. Every area treated is billed under a specific code, each with its own associated fee. After your insurance processes the claim, you will likely have a remaining balance. The timeline for claim processing varies by insurance provider, and delays are possible—especially since we do not perform in-house billing. We work with an external billing company, which may extend the time it takes for you to receive your final bill. If you have not met your deductible, you may be personally responsible for a larger portion of the treatment cost. Please plan accordingly. ⚠️For patients who are not using insurance or are out of network, payment is expected in full at the time of service. We are happy to provide a receipt (super bill) upon request if you choose to seek reimbursement independently from your insurance provider.

to make an Appointment AND CREATE A NEW PATIENT PROFILE CLICK ON “Scheduling” (above on the menu bar).