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Dr. Delicia Paredes, D.C. · Whittier, CA
Illustration of a healthy spine

New Patient Intake Form

Please complete all sections before your first visit. This allows Dr. Paredes to prepare a personalized care plan for you.

Patient Information
Insurance Information
Step 1 of 4 — Personal Info
Current Problem

Select all that apply

Click or tap regions to mark areas of pain or discomfort

Front
Head Neck Upper Chest Abdomen Left Arm Right Arm Left Hand Right Hand Left Leg Right Leg Left Foot Right Foot
Back
Back of Head Back of Neck Upper Back Mid-Back Low Back Left Arm (Back) Right Arm (Back) Left Hand (Back) Right Hand (Back) Left Glute / Hip Right Glute / Hip Left Leg (Back) Right Leg (Back) Left Foot (Back) Right Foot (Back)
Pain Assessment
0
0 — No Pain10 — Unbearable
No pain
0

How much has pain interfered with daily activities this week?

0 — No interference10 — Unable to function
Medical History — Check All That Apply
Family History

Check all conditions present in your immediate family.

Emergency Contact & Language Assistance
HIPAA Privacy Notice

Your Information Is Protected

All personal health information you provide on this form is protected under the Health Insurance Portability and Accountability Act (HIPAA). This practice is committed to maintaining the privacy and security of your health information. Your information will be used solely for the purpose of providing and coordinating your chiropractic care, processing insurance claims, and healthcare operations as described in our Notice of Privacy Practices. We will not disclose your information to any third party without your written authorization, except as required or permitted by law.

Communication Consent
Policies, Terms & Conditions

Please initial next to each policy to confirm your agreement.

Cancellation Policy

If I fail to attend my scheduled appointment without cancellation notice 24 hours prior, I agree to pay a $25 no show/late cancellation fee.

Initial to confirm

Financial Responsibility

I am responsible and directly liable for payment of any outstanding balances. Any deductibles, co-payments, co-insurance or other fees for any office service rendered are payable at the time of my visit, unless other arrangements have been made and agreed upon prior to treatment.

Initial to confirm

Insurance Changes

I agree to notify the office promptly of any changes to my health insurance policy or other pertinent information.

Initial to confirm

Auto / Work Injuries

I have and will notify the office of any previous auto/work related injuries that I may suffer hereafter.

Initial to confirm

Returned Checks

A $25 fee will be charged for all returned checks.

Initial to confirm
Authorization & Informed Consent

Authorization & Assignment

I give authorization to this office to contact my primary care physician and/or relevant health care providers and specialists regarding co-management of my health. I request and authorize direct payment of any medical or automotive insurance company benefits.

Informed Consent for Chiropractic Care

I hereby request and consent to the consultation, examination, and performance of chiropractic adjustments and related procedures. Results are not guaranteed and there is no promise to cure any health condition. I understand there are some risks to treatment, including but not limited to muscle soreness, spasms, sprains, strains, dislocations, disc injuries, fractures and strokes, most with extremely rare incidence. I agree to inform staff of all pre-existing conditions and limitations at any time. I allow Dr. Delicia Paredes Chiropractic to perform such procedures as described. This consent covers the entire course of treatment for my present condition and for any future conditions for which I seek treatment.

Privacy Confidentiality Statement

By signing below, I provide this office with my authorization and consent to use and disclose my personal health information for the purpose of treatment, payment and healthcare operations. I certify that all information I have provided is complete and accurate to the best of my knowledge.

Signature

Check this box if the patient is a minor and you are the parent or legal guardian.

I am the parent/legal guardian of the patient who is of minor age. I hereby give my consent and authorize & request all procedures & treatments as deemed advisable on this minor patient.

Form Submitted!

Thank you for completing your new patient intake form. Dr. Paredes and our team will review your information before your appointment.

If you have any questions, please call us at (562) 415-8209.

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Ready to Feel Your Best?

Join the thousands of Whittier-area patients who trust Dr. Paredes with their family's chiropractic care. Your first visit includes a consultation, thorough exam, and same-day treatment.

Book an Appointment Call (562) 415-8209