Online Forms

Fall City Chiropractic Center offers our patient form(s) online so you can complete it in the convenience of your own home or office.

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Since this office has recently incorporated  Electronic Medical Records (EMR) many forms are eliminated.  Only the page allowing me to bill your insurance company and the financial responsibility clause needs to be filled out.  All other history and information will be entered directly into the system saving paper and time.
  
• Fax us (425-222-9558) your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

No forms are required to be filled out in this area.  I would appreciate you bringing a history of operations (dates and type),medicines (dose and what they are used for), and dates of any previous accidents.  Please feel feel free to either bring or have sent, copies of MRI's or x-rays and or the reports that are pertinent to your complaints

Insurance Questionaire

You can call my billing office at 206-434-6317 and check your current insurance coverage prior to your first visit.  Please bring your card in with you as several copies must be made.

Download & Print Form

Auto Accident Questionaire

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

Please know the date of your accident along with information pertaining to the nature of the collision.  If you have seen other doctors please have their  phone numbers and addresses as we would like to keep in contact with them and if you desire, we would like to send them your progress reports. No online forms need to be filled out.  Please bring with you a claim number from your insurance carrier along with a contact person and billing address.  Generally we do not take third party cases due to the enormous length of time in obtaining settlements. We will be glad to work with you but the charges will be the same as any personal injury claim as "cash" payments do not apply.  Payment will be expected at time of treatment.  We gladly take most credit cards, checks or cash.

For third party accidents we strongly recommend working with a lawyer generally due to the length of time required to close such a case.

Download & Print Form

Member Wellness Registration Form - Optional

This clinic has a Electrical Medical Record system so information will be entered directly into your file.  Please have knowledge of previous illnesses, accidents,operations and injuries. Please bring a copy of all medications that you are currently taking and contact information on any other physicians you are currently seeing.  With your permission we would like to send they progress reports on your improvements.