Online Forms

Fort Campbell Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.


New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!



Marital Status

Assignment and Release

I, the undersigned certify that I (or my dependent) have insurance coverage with the above-listed company and assign directly to Dr. John Curtis all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Accident Information

Type of accident

Patient Condition

Mark an X on the picture where you continue to have pain, numbness, or tingling.
Type of pain
Does it interfere with your
Activities or movements that are painful to perform

Health History

Have you already received treatment for your condition?
Please select all health conditions that apply

Injuries/Surgeries you have had (Include description and dates)

Informed Consent Form

Dear patient,  

Every type of health care is associated with some risk of potential problems. This includes Chiropractic health care. We wish you to be informed about the possibility of any potential problems associated with Chiropractic health care before consenting to treatment. This is called informed consent.

Consent to Treatment

The following points have been explained to me to my satisfaction and I have had the opportunity to discuss them with the doctor and/or other clinical personnel. 


1. I understand that the Chiropractor will use his/her hands or a mechanical device on my body to adjust a joint, and there may be an audible "pop" or "click" as a result of joint movement.  
2. The practice of health care is not an exact science, but relies upon the information related by the patient, information gathered during the examination (and the doctor's interpretation thereof), as well as the doctor's judgment and expertise. Chiropractic health care is no different.  
3. It is not reasonable to expect my doctor to be able to anticipate or explain all possible risks and complications of a given procedure on any particular visit, and I wish to rely on the doctor to exercise professional judgment during the course of any procedures which he/she feels at the time to be in my best interest.  
4. Though infrequent, as with any health procedure, there are certain complications that may arise during chiropractic health care. These complications include soreness, sprains/strains, dislocations, fractures, disc injuries, cerebral vascular accidents, physiotherapy burns, or soft tissue injuries. These complications are extremely rare occurrences.  
5. Chiropractic is a system of healthcare delivery; therefore, as with any other healthcare delivery system, we cannot promise a cure for any symptom, disease, or condition as a result of treatment in this clinic. We can, however, promise that we will give you our best care.  
6. I understand that there are other forms of treatment, including drugs and surgery, which could be treatment options for my condition, but at this time, I choose Chiropractic Care. 


I have read the above consent, or it has been read to me, have had the opportunity to ask questions and receive answers, am comfortable with the information provided, and consent to Chiropractic treatment and management on that basis. In signing this document, I in no way compromise my protection against negligence.

Thank you for taking the time to fill out this form.

Location

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Office Hours

Our Regular Schedule

Monday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Wednesday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Friday

9:00 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday

Closed

Closed

Sunday

Closed

Closed

Monday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Tuesday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Wednesday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Thursday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Friday
9:00 am - 12:00 pm 2:00 pm - 6:00 pm
Saturday
Closed Closed
Sunday
Closed Closed
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