Pink Hill Chiropractic
2017 Chiropractic of the Year
Patient Intake Forms
Please select the button above to fill out your paperwork online through our portal. (No printing necessary) If you are not compfortable, 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. You may bring these forms with you, fax them to the office at 252-751-5038, or send through email at phchiro@gmail.com.
New Patient Intake Form - 2019.doc
Microsoft Word document [685.5 KB]
Please print this off and have it complete before your first visit. You may bring these forms with you, fax them to the office at 252-751-5038, or send through email at phchiro@gmail.com.
New Patient Intake Form - 2019.doc
Microsoft Word document [685.5 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
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