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Anderson Hamo Chiropractic offers our patient form(s) online so they can be completed it 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.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Electronic Health Records Form- Required

Electronic Health Records Intake Form

In compliance with requirements for the government EHR incentive program

First Name:_________________________

Last Name:_________________________

Email address:  [email protected]_________________

Preferred method of communication for patient reminders (Circle one):  Email / Phone / Mail

DOB:   __/__/____         Gender (Circle one):   Male / Female      Preferred Language:  __________________

Smoking Status (Circle one): Every Day Smoker / Occasional Smoker / Former Smoker / Never Smoked

CMS requires providers to report both race and ethnicity

Race (Circle one):   American Indian or Alaska Native / Asian / Black or African American / White (Caucasian)  Native Hawaiian or Pacific Islander / Other / I Decline to Answer

Ethnicity (Circle one):  Hispanic or Latino / Not Hispanic or Latino / I Decline to Answer

Are you currently taking any medications? (Please include regularly used over the counter medications)

Medication Name

Dosage and Frequency (i.e. 5mg once a day, etc.)

Do you have any medication allergies?

Medication Name

Reaction

Onset Date

Additional  Comments

â–¡ I choose to decline receipt of my clinical summary after every visit (These summaries are often blank as a result of the nature and frequency of chiropractic care.)

Patient Signature: _____________________________________________   Date:________________

For office use only

Height: _________       Weight:____________    Blood Pressure:______ /______


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



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Services
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Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.