Useful Forms

Please select from the list below for the appropriate form.  Each form will open in a separate window which you can print for your convenience.

New Patient forms for Chiropractic Care

  1. Fast Track Scheduling: This form can be used by other physicians/medical facilities to refer patients to any of our four doctors at Burkhart & Chapp Chiropractic.
  2. New Patient Initial Evaluation Form: Please complete this form prior to the first time you come into our office for services.
  3. Automobile Accident Evaluation Intake Form:  Please complete this form prior to the first time you come into our office if you will be receiving services due to an auto accident that will be billed to an auto insurance company.
  4. Authorization to Release Medical Records: This form needs to be signed by the patient in order for us to release x-rays and medical records from our office to other health care providers.  This form can also be used by us to request X-rays and medical records be released to us from other health care providers.
  5. HIPAA form: This form needs to be signed by the patient indicating that they have been made aware that their information will not be shared without their consent.  Under HIPAA guidelines, there are also other rules and regulations involving the patient’s legal obligation to pay their co-pays or deductibles.
  6. FABQ form: This form gives the doctor an understanding of how the patient’s pain affects their activities of daily living.  There are two sections to the FABQ, the first being related to general daily activities and the second primarily related to questions about work.  The patient should indicate how much they agree with each question or statement.