{"id":7564,"date":"2020-12-23T11:07:02","date_gmt":"2020-12-23T11:07:02","guid":{"rendered":"https:\/\/molti.samarj.com\/?page_id=7564"},"modified":"2026-11-02T15:43:26","modified_gmt":"2026-11-02T15:43:26","slug":"patient-forms","status":"publish","type":"page","link":"https:\/\/chiro.page\/demo1\/patient-forms\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"\n<div class=\"et_pb_section_0 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_0 et_pb_row et_pb_row_3-4_1-4 et_block_row et_block_row_3-4_1-4\"><div class=\"et_pb_column_0 et_pb_column et_pb_column_3_4 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_menu_0 et_pb_menu et_pb_menu--with-logo et_pb_menu--style-left_aligned et_dropdown_animation_fade et_pb_bg_layout_light et_pb_text_align_right-tablet et_pb_text_align_right-phone et_pb_module et_flex_module\"><div class=\"et_pb_menu_inner_container et_flex_module\"><div class=\"et_pb_menu__logo-wrap\"><div class=\"et_pb_menu__logo\"><a href=\"https:\/\/chiro.page\/demo1\/\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png\" width=\"307\" height=\"137\" srcset=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png 307w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3-300x134.png 300w\" sizes=\"(max-width: 307px) 100vw, 307px\" class=\"wp-image-10240\" \/><\/a><\/div><\/div><div class=\"et_pb_menu__wrap\"><div class=\"et_pb_menu__menu\"><nav class=\"et-menu-nav\"><ul id=\"menu-main-menu\" class=\"et-menu nav downwards\"><li id=\"menu-item-10022\" class=\"et_pb_menu_page_id-home menu-item menu-item-type-post_type menu-item-object-page menu-item-home menu-item-10022\"><a href=\"https:\/\/chiro.page\/demo1\/\">Home<\/a><\/li>\n<li id=\"menu-item-10024\" class=\"et_pb_menu_page_id-377 menu-item menu-item-type-post_type menu-item-object-page menu-item-10024\"><a href=\"https:\/\/chiro.page\/demo1\/about-us\/\">About Us<\/a><\/li>\n<li id=\"menu-item-10030\" class=\"et_pb_menu_page_id-7564 menu-item menu-item-type-post_type menu-item-object-page menu-item-10030\"><a href=\"https:\/\/chiro.page\/demo1\/patient-forms\/\">Patient Forms<\/a><\/li>\n<li id=\"menu-item-10033\" class=\"et_pb_menu_page_id-8687 menu-item menu-item-type-post_type menu-item-object-page menu-item-10033\"><a href=\"https:\/\/chiro.page\/demo1\/extrapage\/\">Extra Page<\/a><\/li>\n<li id=\"menu-item-10034\" class=\"et_pb_menu_page_id-9035 menu-item menu-item-type-post_type menu-item-object-page menu-item-10034\"><a href=\"https:\/\/chiro.page\/demo1\/contact\/\">Contact Us<\/a><\/li>\n<li id=\"menu-item-10243\" class=\"et_pb_menu_page_id-10243 menu-item menu-item-type-custom menu-item-object-custom menu-item-10243\"><a href=\"tel:(404)%20555-7777\">(404) 555-7777<\/a><\/li>\n<\/ul><\/nav><\/div><div class=\"et_mobile_nav_menu\"><div class=\"mobile_nav closed\"><span class=\"mobile_menu_bar\"><\/span><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"et_pb_column_1 et_pb_column et_pb_column_1_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_module et_pb_button_module_wrapper et_pb_button_0_wrapper\"><a class=\"et_pb_button_0 et_pb_button et_pb_bg_layout_light et_pb_module et_block_module\" href=\"#\">SCHEDULE<\/a><\/div><\/div><\/div><\/div><div class=\"et_pb_section_1 et_pb_section et_section_regular et_block_section section_has_divider et_pb_bottom_divider\"><div class=\"et_pb_row_1 et_pb_row et_pb_equal_columns et_block_row inline-buttons-row\"><div class=\"et_pb_column_2 et_pb_column et_pb_column_1_2 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_0 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><h5 style=\"text-align: left;\">new and existing patient paperwork<\/h5>\n<h1>Patient <span style=\"color: #ff8057;\">Forms<\/span><\/h1>\n<div class=\"col-lg-6\">\n<div class=\"hero-title pr-lg-5\">\n<p class=\"text-muted mb-4 pb-2\">We are glad you are here. Learn more about our office, our team and what to expect when you visit.<\/p>\n<\/div>\n<\/div>\n<\/div><\/div><div class=\"et_pb_module et_pb_button_module_wrapper et_pb_button_1_wrapper\"><a class=\"et_pb_button_1 et_pb_button et_pb_bg_layout_light et_pb_module et_block_module\" href=\"#process\">view forms<\/a><\/div><\/div><div class=\"et_pb_column_3 et_pb_column et_pb_column_1_2 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_image_0 et_pb_image et_pb_module et_block_module\"><span class=\"et_pb_image_wrap\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pexels-ryutaro-tsukata-5473182-scaled.jpg\" width=\"2560\" height=\"1707\" srcset=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pexels-ryutaro-tsukata-5473182-scaled.jpg 2560w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pexels-ryutaro-tsukata-5473182-1280x854.jpg 1280w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pexels-ryutaro-tsukata-5473182-980x653.jpg 980w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pexels-ryutaro-tsukata-5473182-480x320.jpg 480w\" sizes=\"(min-width: 0px) and (max-width: 480px) 480px, (min-width: 481px) and (max-width: 980px) 980px, (min-width: 981px) and (max-width: 1280px) 1280px, (min-width: 1281px) 2560px, 100vw\" class=\"wp-image-10082\" title=\"pexels-ryutaro-tsukata-5473182\" \/><\/span><\/div><\/div><\/div><div class=\"et_pb_bottom_inside_divider et-no-transition\"><\/div><\/div><div class=\"et_pb_section_2 et_pb_section et_section_regular et_block_section\" id=\"process\"><div class=\"et_pb_row_2 et_pb_row et_block_row\"><div class=\"et_pb_column_4 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_1 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module et_pb_text_align_center\"><div class=\"et_pb_text_inner\"><h1>Download <span style=\"color: #ff8057;\">Forms<\/span><\/h1>\n<div class=\"col-lg-6\">\n<div class=\"hero-title pr-lg-5\">\n<p class=\"text-muted mb-4 pb-2\">Forms are in the PDF format. You will need PDF software on your computer, although most modern computers sold in the last 10 years come with PDF software out of the box. If yours didn't, <a href=\"https:\/\/get.adobe.com\/reader\/\" target=\"_blank\" rel=\"noopener\">download Adobe Acrobat Reader here<\/a>.<\/p>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><div class=\"et_pb_row_3 et_pb_row et_pb_row_4col et_block_row et_block_row_4col\"><div class=\"et_pb_column_5 et_pb_column et_pb_column_1_4 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_blurb_0 et_pb_blurb et_pb_bg_layout_light et_pb_text_align_center et_pb_blurb_position_top et_clickable et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image et_animated\"><a href=\"#\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/a><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\"><a href=\"#\">Adult New Patient Forms<\/a><\/h4><\/div><\/div><\/div><\/div><div class=\"et_pb_column_6 et_pb_column et_pb_column_1_4 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_blurb_1 et_pb_blurb et_pb_bg_layout_light et_pb_text_align_center et_pb_blurb_position_top et_clickable et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image et_animated\"><a href=\"#\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/a><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\"><a href=\"#\">Child New Patient Forms<\/a><\/h4><\/div><\/div><\/div><\/div><div class=\"et_pb_column_7 et_pb_column et_pb_column_1_4 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_blurb_2 et_pb_blurb et_pb_bg_layout_light et_pb_text_align_center et_pb_blurb_position_top et_clickable et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image et_animated\"><a href=\"#\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/a><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\"><a href=\"#\">Workers Comp Forms<\/a><\/h4><\/div><\/div><\/div><\/div><div class=\"et_pb_column_8 et_pb_column et_pb_column_1_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_blurb_3 et_pb_blurb et_pb_bg_layout_light et_pb_text_align_center et_pb_blurb_position_top et_clickable et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image et_animated\"><a href=\"#\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/a><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\"><a href=\"#\">Auto Accident Forms<\/a><\/h4><\/div><\/div><\/div><\/div><\/div><\/div><div class=\"et_pb_section_3 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_4 et_pb_row et_block_row\"><div class=\"et_pb_column_9 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_2 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module et_pb_text_align_center\"><div class=\"et_pb_text_inner\"><h1>Insurance and Billing <span style=\"color: #ff8057;\">Policies<\/span><\/h1>\n<div class=\"col-lg-6\">\n<div class=\"hero-title pr-lg-5\">\n<p class=\"text-muted mb-4 pb-2\">Have a question about your paperwork? Our team is happy to help.<\/p>\n<\/div>\n<\/div>\n<\/div><\/div><\/div><\/div><\/div><div class=\"et_pb_section_4 et_pb_section et_section_regular et_block_section section_has_divider et_pb_bottom_divider\"><div class=\"et_pb_bottom_inside_divider et-no-transition\"><\/div><\/div><div class=\"et_pb_section_5 et_pb_section et_section_regular et_block_section\"><div class=\"et_pb_row_5 et_pb_row et_block_row\"><div class=\"et_pb_column_10 et_pb_column et_pb_column_1_3 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_image_1 et_pb_image et_pb_module et_block_module\"><span class=\"et_pb_image_wrap\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png\" width=\"307\" height=\"137\" srcset=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png 307w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3-300x134.png 300w\" sizes=\"(max-width: 307px) 100vw, 307px\" class=\"wp-image-10240\" title=\"pc-logo-dk3\" \/><\/span><\/div><\/div><div class=\"et_pb_column_11 et_pb_column et_pb_column_1_3 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_3 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><p style=\"text-align: left;\">All materials on this website including but not limited to text, copy, images and photographs are provided for informational purposes only. This website and related materials are not intended to be a substitute for professional health advice, diagnosis, or treatment.<\/p>\n<\/div><\/div><\/div><div class=\"et_pb_column_12 et_pb_column et_pb_column_1_3 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_blurb_4 et_pb_blurb et_pb_bg_layout_light et_pb_blurb_position_left et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\">(404) 555-7777<\/h4><\/div><\/div><\/div><div class=\"et_pb_blurb_5 et_pb_blurb et_pb_bg_layout_light et_pb_blurb_position_left et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\">frontdesk@example.com<\/h4><\/div><\/div><\/div><div class=\"et_pb_blurb_6 et_pb_blurb et_pb_bg_layout_light et_pb_blurb_position_left et_pb_module et_block_module\"><div class=\"et_pb_blurb_content\"><div class=\"et_pb_main_blurb_image\"><span class=\"et_pb_image_wrap\"><span class=\"et-pb-icon\"><\/span><\/span><\/div><div class=\"et_pb_blurb_container\"><h4 class=\"et_pb_module_header\">1000 Main Street, Atlanta, GA<\/h4><\/div><\/div><\/div><\/div><\/div><div class=\"et_pb_row_6 et_pb_row et_block_row\"><div class=\"et_pb_column_13 et_pb_column et_pb_column_4_4 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_image_2 et_pb_image et_pb_module et_block_module\"><span class=\"et_pb_image_wrap\"><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png\" width=\"307\" height=\"137\" srcset=\"https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3.png 307w, https:\/\/chiro.page\/demo1\/wp-content\/uploads\/sites\/2\/2021\/07\/pc-logo-dk3-300x134.png 300w\" sizes=\"(max-width: 307px) 100vw, 307px\" class=\"wp-image-10240\" title=\"pc-logo-dk3\" \/><\/span><\/div><div class=\"et_pb_text_4 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><p>1000 Main Street<br \/>Atlanta, GA<\/p>\n<p><strong>Tel: (404) 555-7777<\/strong><\/p>\n<\/div><\/div><div class=\"et_pb_divider_0 et_pb_divider et_pb_space et_pb_divider_position_top et_pb_module\"><div class=\"et_pb_divider_internal\"><\/div><\/div><\/div><\/div><div class=\"et_pb_row_7 et_pb_row et_pb_equal_columns et_block_row\"><div class=\"et_pb_column_14 et_pb_column et_pb_column_1_3 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_5 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module link-effect\"><div class=\"et_pb_text_inner\"><p>Copyright CHIROPRACTIC PRACTICE. All Rights Reserved.<\/p>\n<\/div><\/div><\/div><div class=\"et_pb_column_15 et_pb_column et_pb_column_1_3 et_block_column et_pb_css_mix_blend_mode_passthrough\"><div class=\"et_pb_text_6 et_pb_text et_pb_bg_layout_light et_pb_module et_block_module\"><div class=\"et_pb_text_inner\"><p>&nbsp;<\/p>\n<\/div><\/div><\/div><div class=\"et_pb_column_16 et_pb_column et_pb_column_1_3 et-last-child et_block_column et_pb_css_mix_blend_mode_passthrough\"><ul class=\"et_pb_social_media_follow_0 et_pb_social_media_follow clearfix et_pb_bg_layout_light et_pb_text_align_right et_pb_text_align_center-phone et_pb_module et_block_module\"><li class=\"et_pb_social_media_follow_network_0 et_pb_social_media_follow_network et_pb_social_icon et_pb_social_network_link et-social-facebook et_pb_module et_flex_module\"><a href=\"#\" class=\"icon\" title=\"Follow on Facebook\" target=\"_self\" rel=\"noopener\"><span class=\"et_pb_social_media_follow_network_name\">Follow<\/span><\/a><\/li><li class=\"et_pb_social_media_follow_network_1 et_pb_social_media_follow_network et_pb_social_icon et_pb_social_network_link et-social-twitter et_pb_module et_flex_module\"><a href=\"#\" class=\"icon\" title=\"Follow on X\" target=\"_self\" rel=\"noopener\"><span class=\"et_pb_social_media_follow_network_name\">Follow<\/span><\/a><\/li><li class=\"et_pb_social_media_follow_network_2 et_pb_social_media_follow_network et_pb_social_icon et_pb_social_network_link et-social-instagram et_pb_module et_flex_module\"><a href=\"#\" class=\"icon\" title=\"Follow on Instagram\" target=\"_self\" rel=\"noopener\"><span class=\"et_pb_social_media_follow_network_name\">Follow<\/span><\/a><\/li><li class=\"et_pb_social_media_follow_network_3 et_pb_social_media_follow_network et_pb_social_icon et_pb_social_network_link et-social-dribbble et_pb_module et_flex_module\"><a href=\"#\" class=\"icon\" title=\"Follow on Dribbble\" target=\"_self\" rel=\"noopener\"><span class=\"et_pb_social_media_follow_network_name\">Follow<\/span><\/a><\/li><\/ul><\/div><\/div><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"page-template-blank.php","meta":{"footnotes":""},"class_list":["post-7564","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/pages\/7564","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/comments?post=7564"}],"version-history":[{"count":23,"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/pages\/7564\/revisions"}],"predecessor-version":[{"id":13704,"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/pages\/7564\/revisions\/13704"}],"wp:attachment":[{"href":"https:\/\/chiro.page\/demo1\/wp-json\/wp\/v2\/media?parent=7564"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}