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About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact

(503) 585-2585 Appoinment

Phone
(503) 585-2585

Address
1765 State St a,
Salem, OR 97301

Phone
(503) 585-2585

(503) 585-2585 Appoinment

About Us
- Meet the Doctor
- Testimonials
Injury Treatment
Pain Treatment
- Chiropractic Services
- Chronic Pain & Injuries
Patient Center
Contact

Home

Patient Registration Form (General)

Patient Registration Form (General)

Date

First Name*

Middle Initial

Last Name*

Phone *

Address

Cell #

City

State

Zip Code

Work #

SSN #

DL #

Date of Birth

Age

Gender

Male Female

Employer

Occupation

Address

Phone #

Emergency Contact

Phone #

Primary Physician

Phone #

Where you referred to our office by any healthcare provider?

Yes No

INSURANCE INFORMATION / METHOD OF PAYMENT

Cash / Check General Health Insurance Oregon Health Plan Medicare

Health Insurance

ID #

Group #

Subscriber Name

Self Other

Do you have second coverage

Yes No

If Yes

PLEASE INDICATE REGION(S) OF COMPLAINT

Headache Neck Upper / Mid Back Low Back Shoulder / Elbow / Wrist / Hand / Finger Hip / Thigh / Knee / Ankle / Foot / Toe Rib / Abdomen / Chest Other

If other

PATIENT CONDITION

When did your symptoms appear?

Was there a specific injury

Yes No

If yes, explain

Is this condition getting progressively worse?

Yes No Unknown

Overall, rate the severity of your pain on a scale from 1 (Least pain) to 10 (Severe pain)

Is it constant or does it come and go?

How often do you have this pain?

Does it interfere with your

Work Sleep Daily Routine Recreation

Activities that are painful to perform

Sitting Walking Standing Bending Lying

MEDICAL HISTORY

Date of last physical exam

Prior Imaging (X-Rays. MRI, CT Scan ETC.)

Yes No

Date

Previous Chiropractic Treatment

Yes No

Where

Arthritic Condition

Yes No

Cancer

Yes No

Diabetes

Yes No

Heart Problems

Yes No

High Blood Pressure

Vascular Condition

Lung Problems

Yes No

Usual Childhood Diseases

Yes No

unusual Childhood Diseases

Yes No

Currently Pregnant

Yes No

Due Date

Recreational Drugs

Yes No

Tobacco Use

Yes No

How much

Alcohol Use

Yes No

How much

Allergies

Birth Control Medications

Yes No

Exercise

Yes No

Moderate Daily Heavy

MEDICATIONS/ALLERGIES/INJURIES

List Medications

Allergic to Medication

Allergies

Surgeries / Hospitalizations / Injuries

Prior Auto Accident or Work Injuries

AUTHORIZATION TO RELEASE MEDICAL INFORMATION / FINANCIAL AGREEMENT

I UNDERSTAND AND AGREE THAT REGARDLESS OF INSURANCE COVERAGE, I AM LIABLE FOR ANY CHARGES INCURRED AS A RESULT OF SERVICES RENDERED TO ME AT DC CHIROPRACTIC CENTER. IF THIS ACCOUNT IS ASSIGNED TO AN ATTORNEY FOR COLLECTION AND/OR SUIT, THE PREVAILING PARTY SHALL BE ENTITLED TO REASONABLE ATTORNEY’S FEES AND COST OF COLLECTIONS.

I AUTHORIZE RELEASE OF PATIENT MEDICAL RECORDS TO THIRD PARTIES REQUIRING THESE RECORDS FOR DETERMINATION OF FINANCIAL LIABILITY.

Signature

Date

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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DC Chiropractic Center

Address

1765 State St a,
Salem, OR 97301

Phone

(503) 585-2585

View Directions

Monday

9:00 am - 6:00 pm

Tuesday

9:00 am - 4:00 pm

Wednesday

9:00 am - 6:00 pm

Thursday

9:00 am - 4:00 pm

Friday

9:00 am - 6:00 pm

Saturday

Closed

Sunday

Closed

We look forward to hearing from you

Name*

Email *

Phone *

Comments

Please do not submit any Protected Health Information (PHI).

Thank you. Your submission has been sent.

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