Pink Hill Chiropractic 2017 Chiropractic of the Year
Pink Hill Chiropractic    2017 Chiropractic of the Year 

Patient Intake Forms

We offer our new patient paperwork here to make your first visit to our office faster and easier. Please print each of these three documents out, fill them out and bring them with you to your first visit.

New Patient Intake forms
Please print this off and have it complete before your first visit.
2018 New Patient Paperwork.doc
Microsoft Word document [94.0 KB]
PHC EHR History Examination 12-10-11 (1[...]
Microsoft Word document [39.5 KB]
Pink Hill Chiropractic informed consent [...]
Microsoft Word document [31.0 KB]
HIPAA Privacy Notice 092313.doc
Microsoft Word document [45.0 KB]

If you feel your HIPAA privacy protection has been violated you can contact Diane Gore at (252)568-6440 or fill out and file the attached form.  http://www.hhs.gov/ocr/privacy/hipaa/complaints/hipcomplaintform.pdf

Need an Appointment?

(252)568-6400

New Patient Paperwork. Interpretation services now available on site.

 

Call: (252) 568-6400

E-mail: phchiro@gmail.com

Or use our contact form.

Office Hours

Monday 8-12:30 & 3-6

Tuesday 3-6

Wednesday 8-12:30 & 3-6

Thursday CLOSED

Fridy 8-12:30 & 3-6

Where to Find Us

312 West Broadway St

Pink Hill, NC  28572

What's New

Click here for new information.

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