New Patient Intake Form

In an effort to expedite your check-in process, please complete the New Patient Intake Form below prior to your initial visit. If you are unable to do so, please plan to arrive 15 minutes prior to your scheduled appointment time to complete these forms in the office.

Please remember to bring a valid form of identification, such as a drivers license or state-issued ID as well as your insurance card, if applicable.

Spouses/partners are always welcome (and encouraged) to accompany you to your appointment as this provides them with the opportunity to ask our staff any questions they may have.

If you have any questions, please call us at (440) 385-7357. Thank you!

Patient Demographics

Our consultation and examination may indicate that x-rays are necessary to accurately diagnose and analyze your condition. Should x-rays be necessary, we would like to confirm that you are not pregnant at this time. Are you pregnant or is there a chance you may be pregnant?*
Please select one option

Patient Demographics, continued

Insurance Information

Do you have Insurance?*
Please select one option

Current Medications/Supplements

Are you taking any medications or supplements?*
Please select one option

Medical History

Do you have any history of cancer, including Basal Cell or Squamous Cell Carcinoma?*
Please select one option

Medical History, continued
Please check all that apply.







Mental Health

Infectious Diseases


OB/GYN History (females)

Family Health History

Does YOUR IMMEDIATE FAMILY have any of the following?

Surgical History

Surgical History

HIPAA Acknowledgement and Consent

We participate in one or more Health Information Exchanges. Your healthcare providers can use this electronic network to securely provide access to your health records for a better picture of your health needs. We, and other healthcare providers, may allow access to your health information through the Health Information Exchange for treatment, payment or other healthcare operations. This is a voluntary agreement. You may opt-out at any time by notifying the Health Information Management Services/Medical Records Department OR the office administrator.

I, the undersigned, acknowledge that I have had access to a copy of the NOTICE OF PRIVACY PRACTICES. I consent to your disclosure, which you deem necessary in connection with my or my child's condition. This information will only be distributed to your third party payer for purposes of reimbursement for services provided, and only upon direct request of your third party payer.

Authorization and Assignment

Please initial next to each line that applies to you. Thank you.

AUTHORIZATION TO RELEASE INFORMATION (if applicable): You are authorized to release any information you deem appropriate concerning my physical condition to any insurance company, attorney or adjuster, in order to process any claim for reimbursement of charges incurred by me as a result of professional services rendered by you of any consequence thereof.

ASSIGNMENT OF PAYMENT (if applicable): My attorney and/or insurance company are hereby requested to pay direct to Aligned Health Center any money due, the same to be deducted from any settlement made on my behalf. Further, I agree to pay the difference if any, between the total amount of charges and the amount paid by the attorney and/or insurance

company. It is further understood that I, the undersigned, agree to pay the full amount of charges, should my condition be such that is not covered by my policy or if for any other reason the insurance company and/or attorney refuses to pay my claim. Accepting assignment does not release the patient from the responsibility for their yearly deductible or for their co-payment on services provided by the clinic. If you receive payment from your insurance carrier during the period which the clinic has accepted assignment of benefits, you are to bring the check into this office within one week of receipt and endorse it over to the clinic. Failure to do so will result in collection action. In the case of charges that are billed to an insurance company, Aligned Health Center has the right to bill the New Patient Exam and Review of Findings visits for insurance reimbursement

MEDICARE ASSIGNMENT (if applicable): I authorize any holder of medical or other information about me to release to the Social Security Administration and Health Care Financing Administration to its intermediaries or carriers any information needed for this or a related Medicare claim. I permit a copy of this authorization to be used in place of the original and request payment of medical insurance benefits either to myself or to the party who accepts assignment below
ACKNOWLEDGEMENT AND UNDERSTANDING: I hereby acknowledge; A. That there is no insurance company obligated to pay for the services, or if the insurance company involved, or if the insurance company involved refuses to acknowledge an assignment to the doctor, or make other provisions for the protection of the interest of the doctor; or B. If a liability exists and my attorney refuses to agree to protect the interests of the doctor, or if I have not engaged the services of an attorney; then payment of services rendered will be made on a current basis and my bill paid in full as soon as my liability claim is settled or the passage of three months from my last statement, whichever comes first.

Consent to Treat


I hereby request and consent to the performance of specific testing and procedures on me (or the patient named below for which I am legally responsible) as deemed necessary by the providing physicians at Aligned Health Center. I understand and am informed that, while extremely rare, there are some risks to treatment, including, but not limited to: fractures, disc injuries, strokes, dislocations, sprains and strains. I wish to rely on the doctor and treating provider to exercise judgment during the course of the procedure, based on the facts then known is in my best interest. I have read, or have had read to me, the above consent. I have the opportunity to discuss the nature and purpose of chiropractic adjustments and other procedures with the doctor and/or office personnel. I agree to these procedures and intend this consent form to cover the entire course of treatment and for any future condition(s) for which I seek treatment.

Thank you for taking the time to fill out this form.

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Office Hours

Last Patient Appointments are at 12:00 pm and 6:00 pm

Westlake Location


8:00 am-12:00 pm

3:00 pm-6:00 pm


3:00 pm-6:00 pm


8:00 am-12:00 pm

3:00 pm-6:00 pm


3:00 pm-6:00 pm


8:00 am-12:00 pm