Alpine Wellness 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.
- Please bring your completed forms with you to your appointment.
ADULTS
Adult New Patient Health History Form - Required
This let’s us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Adult Reactivation Form - (if you have not been seen in more than 1 year but less than 3 years)
This
let’s us know the history and current state of your health and gives us an update of your status since we saw you last. Also updates treatment consents and administrative records.
CHILDREN
Child New Patient Health History Form - Required
This let’s us know the history and current state of your child's health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Download & Print Form
All Children Under Age 5
Developmental Milestones Download & Print Form
All Children Under Age 7
Birth Records Release Download & Print Form
INSURANCE PAPERWORK
If you have one of the following insurances, additional paperwork is REQUIRED:
United HealthCare
Cypress Care
Medical Resource, LLC
Great-West HealthCare
Evercare
Premera Blue Cross
PacifiCare Health Systems
GE Wellness Plan
Principal Life Insurance Co.
Secure Horizons
Golden Rule, Inc.
Reserve National
Align Networks, Inc.
Health Allies
Universal SmartComp
REQUIRED ADDITIONAL FORMS:
ALL 3 FORMS ARE REQUIRED
Patient Summary Form: Download & Print Form
Neck Index: Download & Print Form
Back Index: Download & Print Form
WEIGHT LOSS
Please go to the WEIGHT LOSS tab to find the appropriate forms
Motor Vehicle Accident Forms
(In Addition To Above Paperwork) - Select Appropriate Age Group
Child MVA History
Download & Print Form
Adult MVA History
Download & Print Form