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New Patient Intake Forms

We offer our paperwork on line so you can complete it in the convenience of your own home. Here are the essential forms we use and why we need them.


Intake Forms

This initial very important form lets us know your history, complaints, lifestyle factors, and your health goals.

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This form is for gathering information necessary for an initial Nutritional Assessment. It can be substituted for our general intake form, above, if you are only coming for a nutrition consultation. However, if you will be receiving other services at our office, you will need to complete both forms even though some of the information is the same. (Sorry, but we don’t want to miss something important.)

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If you are completing these forms for a minor child, please include this consent form.

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Medicare Forms

Patients covered under Medicare insurance please also read and fill out/sign these pages.

Medicare Intake Form

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Please read and sign this form if you are a Medicare patient.

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Privacy Policy

We provide our Office Policy and Privacy Policy for your review. Please also sign the Office Policy and bring it along with the other completed papers from above to your appointment.

pdf iconDownload & Print – Office Policy

pdf iconDownload & Print – Privacy Policy

pdf iconDownload & Print – Receipt of HIPAA


Free AdobeReader(R)

Each form is a PDF document file. If you do not already have AdobeReader(R) installed on your computer, click the Adobe(R) image to download for free.


ABA Family Chiropractic Holistic Health Center | Phone: (419) 535-7818
Chiropractic Websites by Perfect Patients.