Massage Intake Form - Carolina Chiropractic Plus

Massage Patient Forms

Complete Your Massage Intake Form Online or Print & Bring It With Your To Save Time

Download Our Massage Intake Form

Carolina Chiropractic Plus offers our patient forms online so they can be completed in the convenience of your own home or office.

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Download the necessary forms from the list below that pertain to your visit, print them out and fill in the required information.
Bring them with you on your first appointment.

Completion of this form helps us to understand your health history and the current state of your health. What questions, concerns or goals regarding your health and wellness can we help you with? Let us know — we’re here to help you!

Fill Out Our Massage Intake Form Online

Fill out the form below to the best of your ability and the information will be formatted and sent to us directly. To make this process more secure, we don’t ask for some identifying information but we will ask for that when you come in for your visit. Submitting the form online will save you time and stress during your initial visit.

"*" indicates required fields

Step 1 of 7

Insured Person's Name

First Middle Last Suffix

Insured Date Of Birth

Relationship to Insured

Upload Insurance Card (or fill out the fields below)

Drop files here or

Accepted file types: jpg, png, pdf, jpeg, avif, webp, raw, heic, Max. file size: 16 MB, Max. files: 2.

Insurance Provider

Insurance ID Number

Insured Employer Name

Insured Home Phone

Insured Work Phone

Insured Cell Phone

Is the Insured's address the same as Patient?

Yes

Insured's Address*

Street Address Address Line 2 City State ZIP Code

I understand and agree that health and accident insurance policies are an arrangement between the insurance carrier and myself. Furthermore, I understand that this chiropractic office will prepare any necessary reports and forms to assist me in making collections from the insurance company and that any amount authorized to be paid directly to this chiropractic office will be credited to my account on receipt. I also give this power of attorney to endorse checks made out to me to be credited to my account. However, I clearly understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate my care and treatment, any fees for professional services rendered me will be immediately due and payable.

Patient Signature*

Signature Date

Guardian or Spouse's Signature Authorizing Care:

Phone

This field is for validation purposes and should be left unchanged.

Massage Patient Forms

Download Our Massage Intake Form

Fill Out Our Massage Intake Form Online

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