Skip to content

Vert Chiropractic

MOVEMENT NOURISHMENT LIFESTYLE

make appointment
- new patient forms
what to expect
Dr. Marum
patient education

Search for:

new patient forms

Download the form below, print, and fill out prior to your appointment. You may also fill out the electronic form below.

np-intake-2020.pdf Download

Name(required)

Email(required)

Phone Number(required)

Address(required)

City & State(required)

Zip Code(required)

Date of Birth(required)

Social Security Number(required)

Height(required)

Weight(required)

Previous Surgeries or Hospitalization (if none, write "none")(required)

How did you hear about us? Search Engine

Social Media

TV

Friend or Family

Health History:(required) Asthma

Allergies

Heart Disease

Stroke

Diabetes

Anorexia

Alcoholism

Anemia

Arteriosclerosis

Arthritis

Breast Lump

Bloating

Bruise Easily

Cancer

Chest Pain

Cold Extremities

Menstrual Issues

Constipation

Concussion

Seizures

Auto Immune Disease

Digestive Problems

Dizziness

Eating Disorder

Eye Pain or Difficulties

Joint Replacement

Hemorrhoids

Frequent Urination

Fatigue

Hot Flashes

Irregular Heart Beat

Kidney Infection/Stones

Loss of Memory

Loss of Balance

Loss of Smell

Loss of Taste

Loss of Hearing

Nausea

Faint

NONE OF THESE ABOVE

Primary Area of Discomfort:(required)

Please describe the pain at worse (worse at night, in the morning): Level of Pain (0 being no pain 10 being worse pain ever)(required)

What does the discomfort prevent you from doing (health, home, hobbies):(required)

By submitting your information. you hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic. I have had the opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known, is my best interest. If any doctor(s) in this business prescribe needed x-rays with patient denial the business has right to refer patient to another doctor. I have read, and or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition (s) for which I seek treatment.

Δ

Share this:

Twitter
Facebook

Like this:

Like Loading...

Facebook
Instagram

%d bloggers like this: