Online Forms

In order to make your first visit as pleasant as possible as well as save some of your valuable time, Agee Chiropractic Center has provided the patient form(s) needed for your first visit 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.
• Download the necessary form(s), print it out and fill in the required information.
• Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Required Forms

The first five documents are required for all new patients.  Please fill out as completely as possible and sign where indicated. 

New Patient Information and Insurance Payment Authorization
Download & Print Forms

History of Current Symptoms
Download & Print Forms

Pain Drawing and Review of Symptoms
Download & Print Forms

HIPPA Privacy Notice
Download & Print Forms

HIPPA Privacy Acknowledgment
Download & Print Forms

Consent to Treatment of a Minor - this from is only necessacry if the patient is minor under the age of 19 years old
Download & Print Forms

Automobile Accident Questionnaire - this from is only nevessary if your pain is the direct is the direct result of an automobile accident
Download & Print Forms

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!