Download Patient Forms: Consent for Treatment, New Patient Health History, Patient Privacy Policies, Back / Neck Pain Report

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
9302 N. Meridian St., Suite 170
Indianapolis, IN 46280

Please do NOT email them since they contain confidential (protected) medical information.

Form Name	Adobe PDF Reader (*.pdf format)	Microsoft Word (*.doc format)
Accident Injury Report	Click Here	Click Here
Autism Treatment Evaluation Checklist	Click Here
Back Pain Report Form	Click Here	Click Here
Credit Card Guarantee Form	Click Here
Consent for Treatment	Click Here	Click Here
Financial Policy	Click Here
Health Questionnaires (3 parts):
1. Neurotransmitter Assessment Form (NTAF) - includes Medication History Form	Click Here
2. Metabolic Assessment Form	Click Here
3. Health Refocus Questionnaire	Click Here	Click Here
Neck Pain Report Form	Click Here	Click Here
"New Patient" Health History Form	Click Here	Click Here
Notice of Patient Privacy Policies	Click Here	Click Here
Record Transfer Release	Click Here	Click Here
SF-12 Health Survey	Click Here	Click Here
"Signature on File" Permission Form	Click Here
X-Ray Payment Assignment Form	Click Here

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.

Patient Forms: Download Options

Patient Forms: Consent for Treatment, New Patient Health History, Patient Privacy Policies, Back / Neck Pain Report

Brain Balance Program Initial Examination & Diagnostic Testing