Forms

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(Note:If you have had a MOTOR VEHICLE ACCIDENT injury or WORKERS’  COMPENSATIONinjury please skip the GROUP 1 forms and go directly to the GROUP 2 forms, otherwise, use Group 1 forms).

Filling out these forms ahead of your first visit and having them ready when you arrive will greatly increase the efficiency of your first visit.

Why These Forms Are Important:

✤ helpful in making an accurate diagnosis
✤ helpful in determining specific treatment plan components
✤ helpful in consideration of recommendations needed to achieve a positive outcome

GROUP 1 FORMS

-for most patients, unless you have injuries from a motor vehicle accident or have an on-the-job injury, then go to Group 2 Forms

Please download these forms, PRINT AS ONE SIDED documents, fill out, and bring to your first visit.

 

OPTION: Download the forms below (in green) to your device, fill out your forms electronically,  and either print them yourself and bring in the hard copy or send them via email to our office before your visit.  When e-mailing, we appreciate a phone call to alert us to look for your forms on our email ahead of your visit; use this email: doctors@levinchellenchiropractic.com  

GROUP 1 “OPTIONAL” links for e-fillable forms

Which forms are for motor vehicle accident or workers' compensation injuries?

Group 2 forms are specifically for patients with injuries from a motor vehicle accident or an on-the-job injury (workers’ compensation claim); otherwise, please refer to Group 1 Forms. Please download these forms (in orange), print as one-sided documents, fill them out, and bring them to your first visit. These include Vehicle Accident or Workers’ Comp. Health History, Accident Report, Intake Forms, Consent to Treat, Four-Part Form, Insurance Users, Neck Pain Disability Index, Back Pain Disability Index, and Fragrance-Free Policy (read only). Optionally, download e-fillable versions (in blue) and email them to doctors@levinchellenchiropractic.com, with a follow-up phone call.
Please download these forms (in orange), PRINT AS ONE SIDED documents, fill out, and bring to your first visit.

OPTION: Download the forms below (in blue) to your device, fill out your forms electronically,  and either print them yourself and bring in the hard copy or send them via email to our office before your visit. When e-mailing, we appreciate a phone call to alert us to look for your forms on our email ahead of your visit; use this email: doctors@levinchellenchiropractic.com

GROUP 2 “OPTIONAL” links for e-fillable forms

 

Frequently Asked Questions

1 How do I know which forms to fill out for my first visit?

If your injury is due to a motor vehicle accident or a workers' compensation claim, you should use the GROUP 2 forms. For all other patients, please use the GROUP 1 forms. The page provides specific links for downloading forms for each group.

2 Can I fill out the forms electronically or do I need to print them?

You have the option to download and fill out forms electronically for both Group 1 and Group 2. After completing them, you can either print them and bring the hard copy or email them to doctors@levinchellenchiropractic.com. If emailing, a phone call to alert the office to look for your forms is appreciated.

3 Why are these forms important for my chiropractic care?

Filling out these forms helps the clinic make an accurate diagnosis and determine a specific treatment plan tailored to your needs. They are also helpful in considering recommendations to achieve a positive outcome for your health. Having them ready before your visit increases efficiency.

4 What specific forms are required if my injury is from a motor vehicle accident or a workplace incident?

For motor vehicle accident or workers' compensation injuries, you will need to complete the Vehicle Accident or Workers’ Comp. Health History, Accident Report, Intake Forms; Consent to Treat; Four-Part Form; Insurance Users, Neck Pain Disability Index, and Back Pain Disability Index. You should also open and read the Fragrance-Free Policy.