Save valuable time by printing and filling out the forms needed for your first visit with Dr. Bonsall.

Protecting Your Health Information:
What you need to know about the Health Insurance Portability and Accountability Act

All Patients
Please fill out the following forms:

  1. Chiropractic Registration and History Form:
    Page 1 | Page 2
  2. Patient Record of Disclosures
  3. General Pain Disability Index
  4. Oswestry Low Back Pain Scale (if applicable)
  5. Neck Pain Disability Index (if applicable)

 

Car Accident Patients
Please fill out the following forms as well:

  1. Motor Vehicle Accident Form:
    Page 1 | Page 2
  2. Oswestry Questionnaire
  3. General Pain Disability Index Questionnaire
  4. Visual Analog Scale of Neck & Associated Pain (if applicable)

Oxford & United Healthcare Patients
Please fill out the following form as well:

  1. ACN Group Notification Form
  2. ACN Group Patient Health Questionnaire
  3. ACN Group Back Index (if applicable)
  4. ACN Group Neck Index (if applicable)

 

Work Related Injury Patients
Please fill out the following forms as well:

  1. Oswestry Questionnaire
  2. General Pain Disability Index Questionnaire
  3. Visual Analog Scale of Neck & Associated Pain (if applicable)

Child Patients
Please fill out the following form as well:

  1. Consent to Treatment of Minor Child

 

Medicare Patients
Please fill out the following forms as well:

  1. Advance Beneficiary Notice (ABN)

The new patient forms are in Adobe Acrobat Reader format.
Please download the plug-in here:

Adobe Acrobat

Select FILE and then PRINT from your menu.


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