New Patient Intake Form - Dr. MacAdam & Associates

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New Patient Intake Form

New Patient Intake Form

* Indicates required field

Name *

First

Last

Email *

Primary Phone Number *

Secondary Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Birthday (mm/dd/yyyy) *

Occupation *

Emergency Contact Information

Name (First and Last) *

Relationshipt to you *

Phone Number *

Health Information

MSI Health Card Number *

Family Doctor *

Insurance Information

Insurance Compay *

Policy or Plan Number *

Identification Number *

Credit Card Information
We process all payments and co-pays not covered by your health insurance through your credit card

Name on Card *

Card Number *

Expiry mm/yyyy *

CVV *

Reason for Today's Appointment

Primary complaint(s) *

What makes your complaint better? *

What makes your complaint worse? *

When did your complaint begin? *

Rate your complaint (0=no pain, 10=exruciating pain) *

0 1 2 3 4 5 6 7 8 9 10

Is your complaint worse in the: *

Is your complaint getting: *

Health History

Do you have any allegeries? If so, please list and indicate severity. *

List your medications, vitamins, supplements. *

List your surgeries, hospitalizations. *

If you smoke or vape, how many per week? *

If you drink alcohol, how many servings per week? *

Present and Past Health Issues

Please indicate and provide a brief description of any present or past health issue, condition or symptom(s).

Muscular (muscles, tendons, ligaments) *

Skeletal (bones, joints) *

Nervous (brain, nerves) *

Endocrine (hormones) *

Integumetary (skin, hair, nails, sweat glands) *

Immune *

Circulatory (heart) *

Urinary & renal (kidneys, bladder) *

Respiratory (lungs) *

Reproductive (female and male sex organs) *

Digestive (stomach, intestines) *

Family Health History

What health conditions does your family members have? (Grandparents, parents, siblings, children, etc). *

Fees and Policies *

Submit

Chiropractic
60 minute Initial Chiropractic Appointment $175
30 minute Chiropractic Appointment $120
15 minute Chiropractic Appointment $85

Orthotics $500

Massage Therapy
30 minute Appointment $95
45 minute Appointment $110
60 minute Appointment $120
90 minute Appointment $185

Acupuncture

75 minute Appointment $150
60 minute Appointment $120

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Home
Book An Appointment
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Contact
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