Patient Forms and Handbook

Patient Forms

The following forms can be PRINTED and faxed to our office at (240) 264 – 6431 or brought with you on your next visit. DO NOT EMAIL ANY FORMS TO OUR OFFICE. 

 

  • Adult Registration
  • Auto Injury Registration 
  • Change/Update/Revise Medical Records (Re: Amend Medical Records Request)
  • Form Completion (Re: Doctor’s Service Request)
  • Informed Consent to Chiropractic Care
  • Medical Records Request
  • Medical Records Authorization Release 
  • Patient Feedback 
  • Patient Testimonial Release
  • Pediatric Registration
  • Workers’ Compensation Registration

Adult Registration

This form is required for all patients. This form allows us to collect all necessary data of patient’s health and medical history, demographic information, emergency contact, and more. 

 

Auto Injury Registration

This form is required for patients who were involved in an auto/motor vehicle collision. This form allows us to collect all necessary data of patient’s health and medical history, demographic information, emergency contact, information about the auto/motor vehicle collision, and more! 

 

Change/Update/Revise Medical Records (Re: Amend Medical Records Request)

This form is for patients who would like to request an amendment to their medical records. As a patient of our office(s), if you think the information that is contained in your medical and/or billing record is incorrect or inaccurate, you can request a change, update, or a revision to your records. Please note: The doctor has a right to determine if the request (for change, update, and/or revision) will be made. 

 

Form Completion (Re: Doctor’s Service Request)

This form is for patients who would like to request the Doctor to complete paperwork. The only documentation regarding patient health required by law (and included in the office visit charge) is an office note. Therefore, the completion of documents for school, summer camp, childcare, employment physical, and/or disability, the Family Medical Leave Act (FMLA), short-term and long-term care, life insurance, the Department of Veterans’ Affairs disability claims, or other purposes may go beyond routine chiropractic and rehabilitation care. This is a service that cannot be billed to the patient’s insurance carrier and therefore, the patient is responsible for payment of such services. To request the Doctor to complete any paperwork, complete this form and return it to our office. 

 

Informed Consent to Chiropractic Care

This form is required for all patients. Prior to receiving any chiropractic and/or rehabilitation services in this office this form must be read and signed by every patient. 

 

Medical Records Request

This form is intended for patients who are requesting a copy of their medical records for personal use. Other personnel: such as attorneys, and/or healthcare providers are not allowed to use this form. Medical records will not be released to patient unless we receive this form. 

 

Medical Records Authorization Release

This form is intended for patients who are requesting a copy of their medical records to be released to another healthcare provider or authorized personnel. The patient’s medical record cannot be released without written authorization from the patient and/or legal guardian.

 

Patient Feedback 

This form is for patients who desire to share their experiences with us and others. Your (the patient) feedback not only helps to improve our services and/or products, but it also helps our business grow and help to provide more services to those in need. 

 

Patient Testimonial Release

This form is for patients who desire to share their experience with us AND share a photo/video.

 

Pediatric Registration 

This form is required for all patients under the age of 18. This form allows us to collect all necessary data of patient’s health and medical history, demographic information, emergency contact, and more. 

 

Workers’ Compensation Registration 

This form is required for patients who were involved in a work-related injury. This form allows us to collect all necessary data of patient’s health and medical history, demographic information, emergency contact, information about the work-related injury, and more! 

Patient Handbook

The Patient Handbook was created by Harmonious Living Chiropractic: Fitness & Wellness Center, LLC® to will provide you with vital information to assist you in improving your functional health and overall well-being; as well as provide you with answers to questions you may have about being a patient at our office(s).

Click here to download, print, or view the pdf version.