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Patient Forms: Download Options
Patient Forms: Download Options
Patient Forms: Consent for Treatment, New Patient Health History, Patient Privacy Policies, Back / Neck Pain Report
These forms may be downloaded and printed; you may bring
completed forms with you to your visit, or mail them (in
advance) to our office:
Chiropractic Neurology Center
12413 Old Meridian Street
Carmel, IN 46032
Please do NOT email them since they contain confidential (protected) medical information.
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Form Name
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Adobe
Reader
(*.pdf format)
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Microsoft
Word
(*.doc format)
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| Consent for Treatment |
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| "New Patient" Health History Form |
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| Notice of Patient Privacy Policies |
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| Record Transfer Release |
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| "Signature on File" Permission Form |
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| Accident Injury Report |
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| SF-12 Health Survey |
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| Back Pain Report Form |
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| Neck Pain Report Form |
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| X-Ray Payment Assignment Form |
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Note: PDF files require Adobe Acrobat Reader to
view.
To download a free copy of Acrobat Reader in a new window -
Click Here |
For more information about
Chiropractic Neurology and the conditions we treat, or to
schedule an appointment for consultation, call 317-848-6000, or
send
us an email or submit this short form. We will contact
you as soon as possible: ( * = required )
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"Reaching Farther" Program Initial Examination &
Diagnostic Testing
Our
Reaching Farther
Program reflects our goal to
push your child to their full potential and maximize
neurologic function. Initial exam can include:
- Chiropractic Neurologic Exam
- Physical/Occupational Therapy Assessment
- Visual Assessment
- Interactive Metronome Assessment
- IGG/IGE food antibody testing
- Comprehensive digestive stool analysis
- Heavy Metal profiles
- Amino Acid/
Elemental Profiles
- Fatty Acid Profiles
- Other lab tests such as glucose, CBC, etc. may be ordered
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