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.

* Every field marked with a red asterisk must be completed. The form will not submit until all of them are filled in. If a question does not apply to you, type None or N/A rather than leaving it blank.

🚗 Were you in an auto or work accident? Please use our Accident (MVA) Intake Form instead — it captures the accident details and insurance information your claim requires.

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Patient Information

Today's Date *

Last Name *

First Name *

Middle Name or Initial (optional)

Date of Birth *

Age (auto-calculated)

Street Address *

City *

State *

ZIP Code *

Cell Phone *

Work Phone *

Alternate Phone *

Email Address *

Social Security Number * (required for insurance filing)

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 at least one)

(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 — leave a row blank if it does not apply, but once you start a row, finish it)

Name 1

Relationship

Name 2

Relationship

Name 3

Relationship

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.

Every field marked * must be completed — the form will not submit until they are. If a question does not apply to you, type None or N/A.

A confirmation copy will be on file when you arrive for your appointment.

New Patient Intake Form

Patient Information

Chief Complaint & Symptoms

Pain Drawing

Medical History

Lifestyle & Occupational History

HIPAA Consent & Acknowledgment