Barneveld Family Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive at our chiropractic office.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Download the necessary form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
Patient Health Questionnaire and Health History Form - Required
These forms allow us to better understand your health history and current state of your health. In addition to what questions, concerns, goals, regarding wellness you may be interested in discussing.
To save time at your initial appointment you may choose to complete these forms and bring them with you!
Patient Admittance Form - Required
This form provides us with the necessary information to setup your patient account, and process your insurance claims if applicable. Please complete and bring to your initial appointment.
Authorization to Treat Minor
Required if a patient is under 18 years of age. The accompanying parent or guardian must fill out this form to authorize treatment.
Privacy Practices & Disclosure Authorization - Required
Notice of Privacy Practices
After reviewing this document, a patient is asked to sign the following disclosure and release form which acknowledges our privacy practices and authorizes our clinic to treat you and submit your information for marketing purposes and insurance claims.