Download New Patient Forms
ALOHA and Welcome to our practice!
Every time you come in to our office, we want you to have a pleasant and wonderful experience. Your satisfaction and care is our top priority. We have an excellent team that is highly trained and available to serve your every need.
What to bring at your initial office visit:
IDENTIFICATION: Driver's License or any form of picture ID
- INSURANCE CARD: Health Insurance Card (if applies)
- PAYMENT: Payments are due the time services are rendered. We accept cash, checks and credit cards (Visa, Mastercard, HSA).
- NEW PATIENT FORMS: Please download, complete and bring the new patient intake forms with you at your initial office visit.
DOWNLOAD, PRINT AND BRING THE COMPLETED FORMS WITH YOU:
To save you time, Orinda Family Chiropractic has made it convenient for you to download and complete the new patient forms before coming in for your first appointment.
You will need the Adobe Reader to open the files. If you don't already have Adobe Reader on your computer, you can click here to download the Adobe Reader for free.
Download New Patient Forms:
1. Registration & Intake Forms (Required)
2. Informed Consent (Required)
3. PHI Consent Form (Required)
a. Privacy Form HIPPA (Keep for your records)
4. 24 Hour Notice Agreement (Required)
5. Financial Agreement Form (Required)
6. Non-Covered Services Form (Required)
For insurance patients using American Specialty Health Plans (ASHP) : Please complete this additional form
ASHP Intial Health Status (Required)
We appreciate the opportunity to serve you and your family. Please let us know if you have any special requests 925-258-0850 and a team member will be glad to assist you.
Contact Orinda Family Chiropractic: firstname.lastname@example.org
Contact Dr. Jason Wong: email@example.com