New Patients

New Patient Intake Form

Complete this form before your first visit to save time at check-in. All fields are submitted securely to our front office staff.

📋 This form replaces the paper intake packet. You may still complete a paper form at the office if you prefer. Please allow 10–15 minutes to complete all sections.

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Patient Information

Today's Date *

Patient Full Name *

Date of Birth *

Age

Street Address *

City *

State

ZIP Code

Cell Phone *

Work Phone

Alternate Phone

Email Address *

Social Security # (last 4 digits, or leave blank)

Marital Status

Gender

Height

Weight (lbs)

Dominant Hand

Right Left

Employer / Company

Occupation / Job Title

Minor Patient? (Complete if patient is under 18)

Parent / Guardian Name

Relationship

Guardian Date of Birth

Guardian Phone

Spouse / Partner Name

Spouse Employer

Emergency Contact Name *

Emergency Contact Phone *

How did you hear about us? / Who referred you?

HIPAA Consent & Acknowledgment

Notice of Privacy Practices: Mansfield Spinal Care & Rehabilitation is required by law to maintain the privacy and security of your protected health information (PHI). We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

Your health information may be used and disclosed for treatment, payment, and healthcare operations as described in our HIPAA Notice of Privacy Practices. For personal injury and auto accident cases, records may be shared with your attorney (with your authorization), insurance adjusters, and courts as required by law.

I authorize the Practice to use and disclose my health information for: (check all that apply)

(a) Treatment — to provide, coordinate, or manage healthcare and related services (b) Payment — to obtain payment for services, including billing insurance carriers and personal injury claims (c) Healthcare Operations — for quality assurance, auditing, and practice management (d) Authorized Family / Friends — to share appointment information with designated individuals (list below)

Authorized to Receive Health Information (family / friends — optional)

By checking the box and typing your name below, you confirm that:

All information provided in this form is accurate and complete to the best of your knowledge.
You have read and acknowledge the HIPAA Notice of Privacy Practices.
You authorize the disclosure(s) selected above.
You understand this is a digital signature with the same legal effect as a handwritten signature.

Patient (or Guardian) Full Name — Digital Signature *

Date *

I have read and agree to the above statements. I acknowledge the HIPAA Notice of Privacy Practices and authorize the disclosures I have selected. *

Privacy note: This form is transmitted securely. Do not include sensitive financial information. For clinical questions before your visit, call us at (817) 477-2907.

Fields marked * are required. A confirmation copy will be on file when you arrive for your appointment.

New Patient Intake Form

Patient Information

Chief Complaint & Symptoms

Medical History

Lifestyle & Occupational History

HIPAA Consent & Acknowledgment