Patient Forms

Below are the downloadable forms for New and Existing Patients.

If you do not know which forms apply to you, that is okay – our helpful staff will make sure you get the correct paperwork in person when you come in for your scheduled appointment.

New Patient Forms

Have you scheduled or are planning to schedule a New Patient appointment with us? Choose from the list of form options below to fill out and bring in with you to save some time. These forms will only need to be filled out on your first day.

Self Pay – English/Espanol

For Patients who do not have insurance coverage for Chiropractic Care, have chosen to pay out of pocket, will be using an HSA/FSA, or otherwise will be paying on their own. We accept most forms of payment.

Personal Injury or Motor Vehicle Accident Case

For Patients who have been in an accident and may be working with an attorney. When scheduling your appointment with us, please let us know if you are seeking treatment due to an accident, and also please bring in any other medical files, reports, contact information, or documents that may pertain to your case.

Workers Comp

For Patients who are seeking treatment for injuries obtained on the job. Please note: You are responsible for filing and following up on a claim with Workers Comp.


For Patients with Standard Medicare Plans and their Supplements. Please note: Coverage may vary with Medicare Replacement Plans – Prior to scheduling, you may want to confirm coverage with our Billing Department.

Insurance or Mercy Care/Mercy Care Advantage

For Patients with Insurance, Mercy Care, or Mercy Care Advantage. Please note: For Insurance, we recommend you contact your insurance company ahead of time and verify coverage for Chiropractic Care, both with your Insurance Company and your specific Insurance Plan, as coverage may vary by company and by plan within that company. For Mercy Care/Mercy Care Advantage, we also recommend you contact your plan and verify coverage for your status and age.

If you do not have coverage and/or are not covered due to age or status, please contact our billing department to discuss possible options. We are committed to your health and may still be able to work with you depending on your circumstances with Self Pay.

Existing Patient Forms

Commonly known as the “Green Sheets”, these forms are filled out every visit (except your first day). They can be filled out when you come in, where we have them printed on green paper and ready for you on a clipboard, or you can download and print them at home and bring them in with you.

We apologize if you grow tired of filling these out every visit. Originally these forms were only required for Medicare patients, but after the creation of the Affordable Care Act, they have become standard for all our patients, equally. We appreciate your understanding and patience.

Daily Green Sheets – English/Espanol

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