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New Patient Online Forms

Johnson Chiropractic & Holistic Health Center offers our new patient form(s) online so they can be completed in the convenience of your own home or office.

We have three areas from which to choose forms. Please choose the appropriate forms from one of the three sections below.

Click the links below to download, print, and fill them out. Don't forget to bring them with you to your first appointment!


Chiropractic & Acupuncture New Patient Forms

If you were in an automobile accident, please continue down to the Auto Accident section and print the forms found there.

1. Chiropractic & Acupuncture Intake

2. Back Pain Questionnaire - Required if you have BACK PAIN

3. Neck Pain Questionnaire - Required if you have NECK PAIN

4. Headache Questionnaire - Required if you have HEADACHES

If you have Medicare, the following form is required:

Medicare Advance Beneficiary Notice of Non-Coverage (ABN)

If you wish to have your records released for any reason you are required to fill out the form below. This includes release to family, other medical facilities, legal representative, etc.

Records from Johnson Chiropractic to Another Party

Records from another party to Johnson Chiropractic


Nutritional Consulting / Functional Medicine Forms

1. New Patient Functional Medicine Intake & Consent Form

If you wish to have your records released for any reason you are required to fill out the form below. This includes release to family, other medical facilities, legal representative, etc.

Health Records Release Form


Auto Accident Patients

These forms are required if you are seeking treatment due to an automobile accident

The following forms are required for auto injury cases.

1. Auto Injury Intake Form

2. Back Pain Questionnaire - Required if you have BACK PAIN

3. Neck Pain Questionnaire - Required if you have NECK PAIN

4. Headache Questionnaire - Required if you have HEADACHES

5. Health Records Release Form

Insurance Coverage & Reimbursement for Auto Injuries:

**As of 12/15/2017 our office does NOT take third party liens as a result of auto accidents**

Payment Options for Auto Accidents:

  • Health Insurance: If we participate with your health insurance (are in-network) then we will submit to your health insurance for payment.  You are still responsible for any co-pays, co-insurance or other fees due.

  • Out of Pocket: If you do not have health insurance or have a deductible to meet on your health insurance plan, then payment will be due, in full at the time of service, for services rendered. Once care is completed you will be provided itemized receipts if you wish to be reimbursed from the auto insurance company on your own.

  • Attorneys: If you have retained an attorney you will be treated as out-of-pocket, and responsible for payment at time of service. At the end of treatment we will provide you a receipt for care, that can be submitted to your attorney so that you may be potentially reimbursed. 


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