New Patient Forms
Below you will find New Patient forms that you may download, fill-out (by hand) and bring with you for your first appointment with Dr. Giangiulio. All forms must be filled-out as completely as possible.
By having all of these forms already filled-out before your scheduled appointment, it will save you from 15 - 30 min.
Note: depending on your special circumstances, it may be necessary for you to fill out additional forms once you are at the office.
All of the forms are in .pdf. You may need to update your .pdf reader to Adobe Reader 9 or higher to view and properly print the forms.
If needed, you may obtain a free download of Adobe Reader from the Adobe Website by clicking on the below button.
Practice Privacy Notice
HIPAA laws require all patients to review our "Practice Privacy Notice" and to sign the "Reception Form" found at the end of the Practice Privacy Notice" or as a separate form below.
Reception Form
Please review our "Practice Privacy Notice" before signing the "Reception Form".
General Patient Information
This form provides us with all of your contact information.
Case History
This form tells us all about your past and present health status.
Pain Scale Rating (For your use only)
This form is to assist you in filling out your pain scale rating on the case history form. You do not need to bring this form with you.
Fee For Service Policy
This form provides you with inform consent about our office policies and fees. Please review and sign both pages.
Chiropractic Informed Consent To Treat
California has an Informed Consent Law requiring all Chiropractors to obtain written consent from patients and to personally review the form with patients before the patient signs the form, so the patient has the opportunity to ask the doctor questions. A person may not be accepted as a patient unless the form is reviewed and signed. Please review this sample form; however, you will be given a new form to review and sign in the office.
If you have questions in regards to the information provided on the "Chiropractic Informed Consent To Treat" Form or about Chiropractic in general, please read the following "F.A.Q. Sheet of Informed Consent".
F.A.Q. Sheet of Informed Consent
This sheet is designed to answers common questions about Chiropractic, Subluxations and Manipulation. It also provides more scientifically accurate details and realistic information about the "material risks"provided on the "Chiropractic Informed Consent To Treat" Form.
You may also like to read the webpage "About Chiropractic", which provides even more information about Chiropractic via select research abstracts. Click on the above or below link.
Arbitration Form
Due to California's Informed Consent Law, our office must now request all potential patients to sign an arbitration form before a person may be accepted as a patient for treatment in our office. Please review and sign..
Consent to Treat a Minor
This form only needs to be filled-out if the patient is less than 18 years old.
By law, Dr. Giangiulio will not be able to consult with a Minor (person less than 18 years old) unless a Parent or Guardian completes this form.
Other Patient Forms
Below you will find other forms that may be of service to you if instructed by this office to download.
Release of Records "to" Dr. Giangiulio
This form instructs other providers to send Dr. Giangiulio your personal health care information.
Release of Records "from" Dr. Giangiulio
This form instructs Dr. Giangiulio to release your personal health care information to others of your choice.
Summer Intensive Consent to Treat a Minor
This form is for dance organizations to give to their Summer Intensives Students who are less than 18 years of age. Parents may also directly download this form.
By law, Dr. Giangiulio will not be able to consult with a Minor (person less than 18 years old) unless a Parent or Guardian completes this form.