Online Form

Welcome to our office!

Please fill out our Health Record as completely and accurate as possible. If you have any questions, please don't hesitate to ask one of our qualified Chiropractic Assistants.
It is our pleasure to be of service to you. Our commitment to you is to promote the highest quality of health and well-being with Chiropractic care. 

About this Patient 

Please select one option
Marital Status*
Please select one option

Employment Information

Employment Status

Experience with Chiropractic 

Have you been adjusted by a chiropractor before?*
Please select one option

Reason for this Visit

Is the purpose of this appointment related to:
If job related, have you made a report of your accident to your employer?
Has this condition
Does this condition interfere with
Has this condition occurred before?
Have you seen other doctors for this condition?

Place an X on the image below, where you feel pain, numbness or tingling:

Mark your Pain Point

Health Habits

Do you exercise regularly?*
Please select one option
Do you wear:
Medications I Now Take:

Health Conditions 

Please check each of the diseases or conditions that you have had now or in the past. While they may seem unrelated to the purpose of the appointment, they can affect the overall diagnosis, care plan and the possibility of being accepted for care.

Health Conditions:


Are you pregnant?
Are you nursing?
Are you taking birth control?
Do you experience painful periods?
Do you have irregular cycles?
Do you have breast implants?

Initial Consultation Form 

Overall frequency of complaint ( choose one)
Overall intensity of complaint (choose one)
If yes, please select the amount below that you feel your symptoms increase at work:

My Health Insurance

Irrevocable Assignment of Benefits:

In consideration of medical serviced provided to me by Brown Family Chiropractic, P.C. I Irrevocably assign to BFC (Thereafter referred to as "Assignee") any and all insurance benefits available to me (including  but not limited to health insurance.  Personal Injury Protection (PIP) benefits, Med Pay benefits, uninsured motorist benefits, underinsured motorist benefits, optional or compulsory bodily injury coverage, general liability coverage and or worker's compensation benefits to the extent of any bills for medical services provided to me by Assignee.

In the event there is no such insurance benefits available to cover the Assignee's bills, I further assign to the extent necessary to pay in full the bills of the Assignee, the proceeds of any Judgement, arbitration award or settlement.  In the event the bills of the Assignee are not paid in full by insurance benefits, judgement, arbitration, award, or settlement, I personally agree to pay any outstanding balances owed to the Assignee.

The irrevocable Assignment shall in no way limit or abrogate my right to sue any applicable insurer in the event the insurer denies coverage for the Assignee's bills.

By the way of the Assignment, I hereby instruct my attorney and or an applicable insurer to pay the medical bills covered by this agreement directly to Brown Family Chiropractic, P.C., 250 Copeland Street, Quincy, MA 02169.

I agree that a photocopy of the Assignment shall be deemed as effective and valid as the original.


My signature below signifies my agreement for payment in full on a cash basis if I have not provided all the necessary documents and information by the time of the second visit.

I have read and agree to the above statement.

Authorization for Care

AUTHORIZATION: The process of determining suitability for Chiropractic Services involves answering fully and truthfully all questions presented to you either written or spoken regarding your past and present health status. If warranted, a physical examination will be performed that can include but is not limited to vitals measurement, systems evaluation, orthopedic tests, and maneuvers (tests that move and stress parts of the body), neurological test (tests using sharp or dull instruments, smells, or sounds, gently tapping) as well as physical touching. These test and maneuvers will help the Chiropractor determine what may be causing your complaints. Occasionally some temporary soreness and/or stiffness may occur due to the examination, less frequently aggravation of presenting symptoms or initiation of new symptoms. By signing below, you have authorized the performance of a consultation and examination.

ACKNOWLEDGEMENT: We are very concerned with protecting your personnel health information. There may be times our office may need to contact you regarding office matters. By signing below, you have authorized this office to contact you for office related matters and thank you notices for referrals using your first name in the following manner: phone-work-home or mobile, e-mail and regular mail to include sealed envelopes and postcards. Messages may be left on an answering device/voicemail, or with the person answering your phone-home-work-mobile. Also, in accordance with the Health Insurance Portability and Accountability act of 1996 (HIPAA), updated September 23, 2013, this office is obliging to supply you with a copy of the office privacy policies and procedures upon request. This document outlines the use and limitations of the disclosure of your personal health information and your rights as a patient.

I acknowledge that I have been offered a copy of:

Notice of Privacy Practices for Protected Health Information.

Patient Guidelines / Missed Appointments 

We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.  Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.

  • Co-payments: are due at time of service. 
  • Tardiness: Please call if you are running late.  Patients arriving more than 15 minutes late maybe asked to reschedule.
  • Cancellations: We ask that Patients who are unable to keep their appointment call the office at least 24 hours prior to scheduled appointment.  With the exception of emergencies, it is vital that you keep all your appointments. Reminder texts are sent to help you save the date. If you need to re-schedule an appointment, please call our office and arrange for a make-up appointment with our chiropractic assistants. 
  • No Show Appointments:  If an appointment is missed without notification by phone we reserve the right to charge you a $50.00 fee.
  • Repeated Missed Appointments: We will be unable to schedule future appointments for patients having (3) missed appointments and/or cancellations without appropriate notice.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

I understand and agree to all the information written above.

Thank you for taking the time to fill out this form.

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We look forward to hearing from you!

Our Location

250 Copeland Street | Quincy, MA 02169

Office Hours

Find Out When We Are Open

Office Hours


9:00 am-12:00 pm

2:00 pm-6:00 pm


2:00 pm-6:00 pm


7:30 am-12:00 pm


9:00 am-12:00 pm

2:00 pm-6:00 pm