PATIENT FORMS
The forms below are provided for the convenience of our Back In Motion patients. To save time in our office, please download, complete and bring them to your office visit. These forms will be integrated into our electronic medical records system. You will need the free Adobe Acrobat reader to view the documents. If you need to download a copy, you can do so by clicking on the Acrobat icon.
NEW PATIENT FORMS -
Download this PDF to get all eight of our office forms. Please print and fill out the form(s) that are appropriate for your needs and bring them with you to your office visit.
SPECIFIC PAIN REGION FORMS -
If you are experiencing upper (neck) or back pain, please select and fill out the appropriate form below as it applies to your specific regional pain or discomfort -
ADDITIONAL FORMS -
If we are treating a minor, our clinic requires permission from a parent or guardian. Please include the following signed form along with the minor’s new patient forms. This document also includes optional payment authorization for future appointments that are not accompanied by a parent/guardian. (Co-pays, deductibles and co-insurances are the responsibilty of the parent/guardian at checkout.)
If you have recently been in a motor vehicle accident or have experienced a work-related injury, you are required to complete one of the following-
Our Billing Manager will direct you to this form if your insurance company denies your claim and states “only the patient has the right to appeal denials”.
