New Patient Intake

Personal Information

Let's start with your basic information.

Have your ID handy?

Snap a photo of your driver's license to auto-fill your information.

Insurance card?

Scan the front of your insurance card to auto-fill coverage info.

— or fill in manually below —

First Name *

Last Name *

Date of Birth *

Sex

Phone *

Email

Street Address

City

State

Zip

Emergency Contact

Name

Phone

Relationship

Insurance Information

This helps us verify your coverage before your visit.

Do you have insurance?

Insurance Provider

Member ID

Group ID

Do you have a second insurance?

Some people are covered by two plans — for example a spouse's plan, or a Medicare supplement. If that is you, the second one goes here.

Second Insurance Provider

Member ID

Group ID

Auto accident injury?

Date of Accident

Claim Number

Adjuster Name

Adjuster Phone

Attorney Name

Attorney Phone

Medical History

Help us understand your condition so we can provide the best care.

What brings you in today? *

Pain Level (1-10)

No Pain Worst Pain 5

Where does it hurt? (tap the body)

Current Medications

Allergies

Have you had chiropractic care before?

Prior Surgeries

Do you have any of the following conditions?

Consent Forms

Read each form and sign it. The next one opens when you finish the one in front of you.

Review & Submit

Please review your information before submitting.

Your appointment

Do you already have an appointment with us?

By checking this box, I consent to receive recurring informational and appointment-related text messages from NJBack Chiropractic Center at the mobile number I provided. I understand that consent is not a condition of receiving any goods or services, that message and data rates may apply, that message frequency varies (typically 2–5 per week), and that I can reply STOP to opt out or HELP for help. I have read and agree to the Terms & Conditions and Privacy Policy.

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All Done!

Your intake form has been submitted successfully. When you arrive, just check in at the kiosk. Everything will be ready for you.

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