Gillman Chiropractic, PC offers forms online so they can be completed in the convenience of your own home or office, before you even arrive to our office. To avoid the need to complete forms in the office, we highly recommend that you utilize a computer or tablet vs a cell phone to fill out forms.
- A new patient is someone who is meeting with the doctor for the first time or who has not been in for treatment in the past 3 years.
- Our new patient form and patient self assessment tools are fillable online. Just click the link, complete the form and submit. Your past medical history and surgeries are important. Omitting information prevents us from providing the best care possible. So please fill in all fields. Do not write N/A.
- Some patients may require additional forms that will either be emailed to you prior to your appointment or completed when you enter the office.
- Please fill out the "Patient Self Assessment Questionnaire" that best suites the condition that you want the doctor to focus on.
Health History Forms
Click the appropriate forms below:
- New Patient - Fillable online and sent directly to us
- Motor Vehicle Patient - Fillable online and sent directly to us
- Worker's Compensation Patient - Fillable online and sent directly to us
- Consent to Treatment of a Minor Child - Fillable online and sent directly to us
- DOT Driver's Health History - Print only form
If you are an existing patient with a new condition or returning for treatment after a 6 months, but under than 3 years:
- Returning Patient / New Condition - Fillable online and sent directly to us
Reminder: Do not complete this form if you are returning to treatment after more than 3 years.
Patient Self Assessment Questionnaires
To assess your daily activity limitations, please choose one of these questionnaires. These forms are fillable online and sent directly to us:
- Headache
- Lower Back Pain
- Neck Pain
- Multiregional Spine Pain
- Arm/Shoulder/Hand Pain
- TMD - Jaw Pain
- Lower Extremity Pain
- Activities of Daily Living (Medicare)
Annual Coverage and Non-Coverage Forms
The following forms are descriptions of how your insurance company may or may not cover chiropractic and other services provided in our office. Please choose the link for your insurance company and complete information as needed. If your insurance company is not listed complete the Non-Covered Form only:
- Blue Cross Blue Shield
- Cigna
- Medicare (Including Medicare Advantage plans)
- Tufts
- United Health Care
- Non-Covered Services