Download, Print, Complete
Online Forms
Old Mill Chiropractic & Family Wellness offers our patient form(s) 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 form(s), print it out and fill in the required information.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
HIPAA Notice and Insurance Guidelines – For your Information
This first form lets you know your HIPAA rights with our pamphlet. The second document informs you of our insurance guidelines, and how we and your health care provider manage your claims while you are in the hands of our practice.
New Patient Health History Form – Required
This lets us know the history and current state of your health. We have a general one for teens and adults as well as a pediatric one. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Functional Medicine
If you are interested in seeing how Dr. Eric can help you improve your health, naturally, and have scheduled an appointment, please fill out the form below and have it brought in before your next appointment.
Auto Accident and Personal Injury
The following paperwork is for those of you who have been injured and are coming in to our practice to seek relief. The first two forms require information from your accident and the appropriate insurance. Claim numbers are required. The lien is a waiver that you sign with us indicating that you are not responsible for payment and will go through your insurance or lawyer. If the case falls on you, the total amount will be billed to you. The last two forms are specific to each part of your body. Please answer accordingly.
Client Experience Questionnaire
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