Pediatric Form: Please fill out everything completely and to the best of your knowledge.

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    HIPAA PATIENT INFORMATION RELEASE FORM:

    In general, the HIPAA privacy rule gives individuals the right to request confidential communications or that a communication of private health information be made by alternative means, such as sending correspondence to the patient’s office instead of the their home. Occasionally our office will send out greeting cards, reminder postcards, call and/or email you regarding an appointment, etc. Please let us know which form(s) of communication you would prefer to be contacted by. By signing this form, I am acknowledging that I have been notified of the Privacy Practices utilized in this office and may request a copy of such document. Please check all that apply below.
    This is a required question
    This is a required question
    This is a required question
    This is a required question

    Belcher Chiropractic May Speak With/Regarding:

    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
    This is a required question
Request edit access