New Patient Forms

On this page, you will find New Patient forms that you
can print out and fill in before arriving at our Office.
This will save you time when you arrive for your first visit.

Please read our Privacy Statement

For your convenience, they are listed in two formats.
Microsoft Word and PDF.
Please use only one format per form.

Microsoft Word Use

You will be asked to "Open" or "Save" the Microsoft Word file.
Click "Open" then fill out the form and print it.
Close the new window
to return to this page for
the remaining forms.

PDF Format Use

After printing out the PDF file,
Close the new window
to return to this page for
the remaining forms.

You will need a "PDF Reader" to view the PDF files.
If you do not have a PDF reader, you can
download a free Adobe PDF Reader here.

Need more information?
Click and we will answer.

Don't forget your Complimentary Exam.

Microsoft Word Format
You will need one copy of each form.

Financial Responsibilty Form In Microsoft Word
All New Patients.

Patient History Form In Microsoft Word
All New Patients.

HIPAA - Privacy Notice In Microsoft Word
Print and sign only. All New Patients.

Automobile/Personal Injury Form In Microsoft Word
Only if you have had an Auto Accident or a Personal Injury.

PDF Format
You will need one copy of each form.
Only if you did not use Microsoft Word format.

Financial Responsibilty Form PDF
All New Patients.

Patient History Form PDF
All New Patients.

HIPAA - Privacy Notice PDF
Print and sign only. All New Patients.

Automobile/Personal Injury Form PDF
Only if you have had an Auto Accident or a Personal Injury.

If you are filing for Ohio Workmens Compensation you will need this form.

Ohio Workmens Compensation
This form is available only in PDF. (Includes Instructions)

First Report Form PDF

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Any use or redistribution, in any form or medium, of any Copyrighted material copied from this site
without the express written consent of the owners of the Copyright is prohibited and punishable by law.

American Family Chiropractic Center 5250-B Courseview Drive Mason, Ohio 45040-2370