Ultima Chiropractic at World Gym - 600 Winters Ave. - Paramus, NJ 07652 - 201.634.8755 - DIRECTIONS

Patient Intake Forms

Privacy Notice - This form describes how chiropractic and medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

1. Fill out
   Online Pre-Registration Form
   
   
2. or...
   DOWNLOAD PRINTABLE PDF FILE
   
   
3. Patient Authorization Form - download read and fill out for appointment reminders and scheduling related matters.
   DOWNLOAD PRINTABLE PDF FILE
   
   

HIPAA Compliance Laws

1. Patient Authorization - regarding chiropractic care being provided in "open adjusting" environment.
   DOWNLOAD PRINTABLE PDF FILE
   
   
2. Patient Authorization - for contact regarding chiropractic care, related health services and/or related health products
   DOWNLOAD PRINTABLE PDF FILE
   
   
3. Patient Authorization - regarding chiropractic care being provided in "open door" environment.
   DOWNLOAD PRINTABLE PDF FILE
   
   View HIPAA Website
   
   
   
   

PATIENT INTAKE FORMS \ HIPAA Compliance Laws

Please fill in on-line registration form, download,read, print, sign and bring in following forms