New Patient
Forms

Welcome to Hines Health Chiropractic!

We offer our patient forms online so you may complete them at your convenience. Please bring your completed forms when you arrive for your appointment.

If you prefer to complete the forms at our office we'll provide them for you when you arrive; please arrive 15 minutes prior to your appointment time.

Please bring your driver’s license and insurance card (if applicable) to your first visit. We prefer payment in check or cash, but will accept credit/debit payment for above $20.

You will need Adobe Reader to open the files, and if you do not already have this application you may download it for free by clicking here.

New Patient Forms

Please Complete and Print ALL 4 Forms for New Patients:

*HIPAA - Privacy & Polices - for your information only, no need to print, but please read before signing Policy page above.

Motor Vehicle Collision

Complete ONLY if Involved in an Auto Accident
(in Addition to the New Patient Forms Above)

Heat and Ice Application

Optional Information