Adult Health History Form

Welcome to our office!

Please fill out our Health Record as completely and accurately as possible.

Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

About You

Reason for this Visit

Is the purpose of this appointment related to:
Has this condition occurred before?
Have you seen other doctors for this condition?
Has this condition
Does this condition interfere with

Place a mark on the image below, everywhere you feel pain, numbness or tingling,  even if it is not the primary reason for your visit today. 

Mark your Pain Point

Health Conditions 

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Health Conditions:
Medications I Now Take:


Are you pregnant?
Are you nursing?
Do you experience painful periods?
Do you have irregular cycles?

Awareness of Chiropractic Principles

Chiropractic care seeks to improve health through natural means, without drugs or surgery. The primary goal of this office is to remove misalignment of the spine, allowing the body to function at its best. Our method for correcting the spine is using specific Upper Cervical technique. This procedure is scientifically researched, safe, and effective. We take x-rays to determine the area of misalignment. We do not diagnose or treat diseases.  

People see Chiropractors for a variety of reasons. Some go for relief of pain, some to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your treatment program. 


We accept Cash, Credit/Debit and HSA/FSA cards.  Payment is due at time of services. All office visits without treatments are a service fee of $35.00. All delinquent accounts, 30 days past due will be charged an interest rate of 4.75% per month.  

Third Party Liability Injuries. If you receive treatment as a result of a third party liability injury(for example: motor vehicle accidents, premises liability, or other general liability claims against third parties), the balance for services rendered is considered due in full at the time of the service. Because Upper Cervical Chiropractic of Utah does not protect charges incurred relating to or arising out of third party liability, we will not accept a delay in payment due to settlement disputes and/or litigation. We will not accept a letter of protection from an attorney as a guarantee of payment or assignment of third party insurance payments. Upper Cervical Chiropractic of Utah cannot act as administrator to resolve financial arrangements. We may agree to bill a third party insurance company of an at-fault party involved in an accident as a courtesy to you. To bill your claim directly, you must provide us all necessary information to confirm coverage for these payments with the auto/third-party carrier. Regardless of whether we submit your claim to third-party insurance, as the patient, you are ultimately responsible for payment.

In the event that the account becomes delinquent the undersigned agrees to pay a collection fee not to exceed 40% of the unpaid balance. In the event a lawsuit is brought against you to collect the unpaid balance, the undersigned further agrees to pay court costs and reasonable attorney fees in addition to the collection fee.

Acknowledgement By signing below, each of the undersigned acknowledges that: (i) I have been provided a copy of the Upper Cervical Chiropractic of Utah. LLC: PATIENT FINANCIAL RESPONSIBILITY STATEMENT; (ii) I have read, understand, and agree to their provisions and agree to the specified terms; (iii) I agree to pay all charges due (or to become due) to Upper Cervical Chiropractic of Utah LLC for the below Patient’s care and treatment

Authorization for Care

I hereby authorize the Doctor to work with my condition through the use of adjustments to my spine, as he or she deems appropriate. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis.

Missed Appointments 

We care about you and it would be a disservice to you if we did not emphasize the importance of your own commitment to the care plan. 

  • Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
  • With the exception of emergencies, it is vital that you keep all your appointments. Text reminders are provided to help you. If you need to re-schedule an appointment, please call or text our office and arrange for a make-up appointment. Voicemail/Text is available 24 hours a day. 
  • In the case of a no show or cancellation without a 24 hour notice by phone or text, we reserve the right to charge you a $35.00 fee.
  • If you are more than 15 minutes late for your appointment, you will be asked to reschedule and charged the no show/cancellation fee. 

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Emergency Contact with Consent to Release Medical Information

If unable to reach me:

This Release of Information will remain in effect until terminated by me in writing.

Agreement to Receive Electronic Communication

I agree that Upper Cervical Chiropractic of Utah, LLC , may communicate with me electronically at the

email address and cell phone number I provided above. I am aware that there is some risk that third parties

might be able to read unencrypted emails or text messages. I am responsible for providing Upper

Cervical Chiropractic of Utah, LLC updates to my email address and cell phone. 

I can withdraw my consent to electronic communications by asking for a new HIPAA form in office.


Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement. 

**You may refuse to sign this acknowledgement**

I have received a copy OR read this Office's Notice of Privacy Practices.
I acknowledge and allow Upper Cervical Chiropractic of Utah, LLC, to
share my information with those already stated within the Notice of
Privacy Practices.


The Health Insurance Portability and Accountability Act of 1996 (HIPAA) was designed to protect your rights to privacy of your protected health information. This act was passed with the intent to provide security of the electronic transmission of your individual health information. At Upper Cervical Chiropractic of Utah, LLC your personal health information (i.e. x-rays, initial medical history, progress record, etc.) and your public or nonpublic personal information (i.e. your Social Security Number, your name, address, and phone number, your date of birth, marital status, etc.) are never shared with any outside sources unless you personally request and authorize us to do so. We are contracted with government insurance agencies and a clearing house, and may, in rare instances transmit your insurance information electronically.

Is your Personal Information Shared with Others?
We have no affiliates, non-affiliates, or third parties with whom we share or sell your private, public or nonpublic information. Thus, your personal information is never disclosed outside this office without your request and authorization.

Do we share your patient records with insurance companies when they request it?
We are not providers for any private insurance network. We do not contract with any insurance company to provide care to you. However, if you are insured and your benefits include chiropractic care, we will be glad to provide a monthly receipt for you to submit to your insurance company.

What other means do we use to protect your private health information?
We have created a written procedural plan to describe in detail how we internally protect your records and insure the privacy of your health information. Some of the following points offer the general means we use to protect your private health information and public and non-public information:
- We secure the premises when the office is closed.
- We have emergency disaster plans for restoring electronic patient records.
- Security measures are in place to protect electronic and hard copy data.
- We permanently dispose of your paper and electronic records when required.
- We randomly audit patient records to eliminate or detect errors and/or omissions of information.

What rights do I have to protect the privacy of my health information?
As a new patient, we may ask your permission to take photographs for personal identification, to include your name on our mailing list, to receive our newsletter, or for any other administrative use of your health information we deem necessary. You have the right to refuse our requests. You have the right to revoke any authorization that you may have previously given us. Your records are available for your review or copies can be made for you at a small administrative fee.

I hereby authorize Upper Cervical Chiropractic of Utah, LLC. to obtain a photograph of me or my child for the purposes of my personal identification to be posted with my medical records and if provided, my video or written success story may be used on social media outlets and website.

If you have any comments, questions, requests, or complaints regarding our Privacy Policy, please feel free to contact our office at (801) 224-1121.

I have read and I understand this Privacy Policy for Upper Cervical Chiropractic of Utah, LLC.

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

Hours Of Operation


9:00 am-5:00 pm


9:00 am-5:00 pm


9:00 am-5:00 pm


9:00 am-4:00 pm







Office Location

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