Download, Print, Complete
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
New Patient Health History Form – Required
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.