New Patient Forms
Below you will find New Patient forms that you may fill-out online and/or download and fill-out by hand. Please bring these forms with you for your first appointment. All forms must be filled-out as completely as possible.
By already having these forms filled-out before your scheduled appointment, you will save your self 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 requires us to provide our Practice Privacy Notice to all patients for their review. Please read the notice and also sign the below "Reception Form" to indicate that we have made our Privacy Notice available to you.
Reception Form
Please review the above Practice Privacy Notice before signing the Reception Form. We must have all patients sign the Reception Form to prove that we have made our privacy policies available for your review.
General Patient Information (On-line fillable)
This form provides us with all of your contact information. It may be filled out on-line. When finished with typing the form, please print it and then sign and date the form where appropriate.
Case History (On-line fillable)
This form tells us all about your past and present health status. It may be filled out on-line. When finished with typing the form, please print it and then fill in the pain rating section on the front page. Also sign and date the form where appropriate.
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.
Note about Fees: To see if you are eligible for a contractual discount, click on the "PayPal Donation" Button on the lower left side of this page. It will take you to another page that list all of the contractual discounts available.
Chiropractic Informed Consent To Treat (Sample Form)
(For viewing Purposes only)
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. This allows the patient the opportunity to ask their doctor questions about the risks and benefits of Chiropractic treatments.
A person may not be accepted as a patient unless the form is reviewed and signed.
To save time, please review this "non-executable" sample form before your office visit. Note, you will be given a new form to review and sign in the office.
The form also provides information about Chiropractic care, Subluxations and Adjustments. 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 patients to sign an arbitration form before a person may be accepted as a patient or to continue 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. These forms are not needed unless we have asked you to download them.
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.