New Patient Application Form

Laurelhurst Chiropractic

Information and Forms for New Patients

Laurelhurst Chiropractic is thrilled to have you join us on your journey to better health and wellness. To ensure we provide the best care possible and fully understand your needs, we’ve made the process simple and easy for you. We kindly ask that you complete our patient intake form before your first appointment. This form helps our team understand your unique needs, prepare for your visit, and customize your treatments accordingly. Please fill out the medical intake form provided by the clinic below.


Don’t hesitate to contact us with any questions!

New Patient Application

We're excited to welcome you as a new patient! This form is designed to help us understand your health goals, medical history, and preferences more thoroughly.

If completing the form for a pediatric patient, please select "YES" on the form when asked if the appointment is for a "child development concern or condition."


If you are coming in for a personal injury (auto accident) or workers' comp claim, please select that as the "reason for your visit."


Also, our office will be sending you a signature request via Adobe Sign once your appointment is scheduled. Keep an eye out for that in your email!

New Patient Application Form (Ages 6 and Up)

Welcome aboard! We’re thrilled to have you as a new patient. This form helps us get to know you better by addressing your health goals, medical history, and preferences. It serves as the starting point for creating a personalized plan just for you.

Welcome to Our Office!

Pediatric History Form (Ages 0-5)

For our young patients, we’ve got a form that covers everything from allergies to milestones. This helps us give the best care to our little champs. If your child is under 5 years old, we ask that you complete the pediatric form on their behalf.

Pediatric History Form

Disclaimer About Infant Chiropractic Care: 


For children under 1-2 years old, chiropractic care is often seen by insurance companies as "investigational" treatment. Whether it is a manipulation or just muscle work, there are many times when we send claims to the insurance provider for an infant's treatment and it comes back  uncovered regardless of the plans limits and benefits for chiropractic care. This can be frustrating as we and you know you child needs this care in order to function and keep growing in their best healthy selves and you may have even been referred by your pediatrician! We do our best to appeal these decisions by the insurance companies but a lot of the time they will not budge on their decision. It does help to have a referral from a pediatrician on file for the times when we need to appeal these decisions, so if you do have one please let us know and we can get that saved to your child's file. If the decision to not cover services is upheld by the insurance company there is not much more we can do and the care will be subject to the out of pocket rates. 

It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.


In Network


Anthem Regence 

BCBS

Moda


Providence

Kaiser Physician Referred (You need a referral from your Kaiser PCP before your appointment if you have this plan)


American Specialty Health

Pacific Source


HealthNet

*Medicare (as of 11/19/2024 we are not currently accepting any new Medicare Patients. This will update as we are ready to accept new Medicare Patients) 

CHP (Kaiser Self-Referred)

Cigna


We are NOT IN NETWORK with Medicaid (This includes Oregon Health Plan, Healthshare of Oregon and any other entities funded by Medicaid. Please double check that your insurance plan is not through Medicaid as they will sometimes send you a card that says "Kaiser" (for example) but the plan is still administered through Medicaid and we cannot bill them.)


If your insurance plan is not listed in this table we are likely out of network and you can expect to pay out of pocket for services rendered. We do not send claims to out of network insurers but when you pay out of pocket we are happy to provide you with a superbill to submit to your out of network insurer for any reimbursement they might give you for out of network services.

Automobile Accident/Workers' Compensation Form

Accidents happen, and we’re here to help you bounce back. This form lets us understand the details so we can assist you effectively and get you back on track. Complete this form if you will be seen under a personal injury (auto accident) or workers’ compensation claim.

Automobile/Personal Insurance Accident or Work Comp Questionnaire

Emergency Contact