Patient Forms

Filling out these forms prior to your appointment is appreciated and will save us time when you arrive. If you need assistance filling out these forms, you may wait until you are in our office and we will assist you, in which case please arrive 15 minutes early.

If you have been in an auto-accident and I am billing your MedPay Insurance OR If you have been injured on-the-job and I am billing your Arizona State Workmans’ Comp insurance, please print and fill out the following forms:

Health Intake

Injury Information 

Neck Pain and Disability Index (only fill this out if you have neck pain)

Low Back Pain & Disability Index  (only fill this out if you have low back pain)

Massage Cancellation Policy

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If you are coming in for massage and not seeking treatment from an auto-accident or on-the-job-injury, please print and fill out these forms:

Health Intake

Massage Cancellation Policy

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If you need your doctor to write you a prescription for Medical Massage, please print this form, have her fill it out and fax it to me (520.448.0819) or you can bring it in on your first appointment:

Medical Massage Prescription

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Other forms: (only print these if directed by my office or your attorney to do so.

Authorization to Use and Disclose Health Care Info

Patient’s Release of Health Care Info

Contractual Guarantee of Payment for Health Care Services

 

 

5675 N. Oracle RD #3203 Tucson, AZ 85704

(Located inside Synergy Chiropractic on the 2nd floor. There is an elevator)

phone: 520.858.0350 fax: 520.448.0819