Online Forms
Erickson Clinic of 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.
- Fax us your printed and completed form(s) or bring it with you to your appointment.
Documentation is very important - especially in the case of insurance filing. Please take a moment and fill out the following forms thoroughly.
*AT THE PRESENT TIME, OUR SITE DOES NOT HAVE THE CAPABILITY FOR PATIENTS TO COMPLETE FORMS ELECTRONICALLY. THESE FORMS MUST BE PRINTED AND COMPLETED.*
New Patient Form Part 1
Download & Print Form (This form is required for treatment if you are a new patient.)
New Patient Form Part 2
Download & Print Form (This form is required for treatment if you are a new patient.)
Health Questionnaire
Download & Print Form (This form is required for treatment if you are a new patient.)
Neck Pain Survey
Download & Print Form (This form is required for treatment if you are a new patient with headaches, upper back pain, and/or neck pain.)
Low Back Pain Survey
Download & Print Form (This form is required for treatment if you are a new patient with low back pain, lower extremity pain, and/or foot or ankle pain.)
Notice of Privacy Practices (HIPPA)
Download & Print Form (This form is required for treatment if you are a new patient.)
Informed Consent to Treatment
Download & Print Form (This form is required for treatment if you are a new patient.)
Personal Injury/Auto Accident Patient Forms (These forms are required in addition to the above forms if you were involved in an automobile accident or have a worker's compensation injury.)
Download the Free AdobeReader®
3D Spine Simulator
Launch 3D Spine Simulator
Contact
3000 Bethesda Place, Suite 401-402
Winston-Salem, NC 27103
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- Phone: 336-760-1333
- Fax: 336-760-9111
- Email Us