Patient Forms

Downloadable patient forms for your convenience

You Can Now Submit Your New Patient Forms Online!

People told us they wish they could easily submit their information online without having to download, print and email/fax/bring in their forms. Well you talked and we listened. We now offer an online form so you can submit your information online and save more time when you come in for your consultation.

Download Our New Patient Intake Form

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

If you do not already have AdobeReader® installed on your computer, Click Here to download.
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 New Patient 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.

Step 1 of 9

Spouse Name
Prefix First Middle Last Suffix
Is Spouse a Patient?
- Yes
- No
Spouse Date of Birth
Month
Day
Year
Spouse Home Phone
Spouse Work Phone
Spouse Cell Phone

Employer Name
Employer Phone
Employer Address
Street Address Address Line 2 City State ZIP Code

Insured Person's Name
First Middle Last Suffix
Insured Home Phone
Insured Work Phone
Insured Employer Name
Relationship to Insured

Emergency Contact
First Last
Emergency Contact Phone
Emergency Contact Work Phone

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 me are charged directly to my 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.
Release of Information*
Release of Information
In the event that Dr. Moffitt believes it is necessary for a second opinion or finds it necessary to contact my primary or treating physician, I authorize this office to release my medical records arising from said treatment.
I agree to the release of information clause.*
Assignment of Proceeds*
I agree to the assignment of proceeds clause.
Assignment of Proceeds
I hereby direct all payers to release any information regarding any coverage or benefits to pay directly to Carolina Chiropractic Plus. I authorize this office to release any information to insurance carries regarding my treatment to facilitate collection. I agree that all provisions to this agreement are reasonably necessary for the protection of the rights and interests of Carolina Chiropractic Plus and myself.
Patient Signature*
Signature Date
MM slash DD slash YYYY
Guardian or Spouse's Signature Authorizing Care:
sign again

Patient Forms

Downloadable patient forms for your convenience

You Can Now Submit Your New Patient Forms Online!

Download Our New Patient Intake Form

Fill Out Our New Patient Intake Form Online

Step 1 of 9

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