{"id":226850,"date":"2021-12-20T08:23:11","date_gmt":"2021-12-20T14:23:11","guid":{"rendered":"https:\/\/freeportfamilychiro.com\/?page_id=226850"},"modified":"2022-12-23T10:40:00","modified_gmt":"2022-12-23T16:40:00","slug":"patient-forms-2","status":"publish","type":"page","link":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/","title":{"rendered":"Patient Forms"},"content":{"rendered":"[vc_row pix_particles_check=&#8221;&#8221;][vc_column][vc_column_text]\r\n<h4><span style=\"color: #000000;\"><em><strong>Freeport Family Chiropractic &amp; Acupuncture offers our patient form(s) online so they can be completed in the convenience of your own home or office.<\/strong><\/em><\/span><\/h4>\r\n&nbsp;\r\n<ul>\r\n \t<li>\r\n<h5><span style=\"color: #000000;\">If you do not already have AdobeReader\u00ae installed on your computer,\u00a0<span style=\"color: #0000ff;\"><a style=\"color: #0000ff;\" href=\"https:\/\/www.adobe.com\/acrobat\/pdf-reader.html\">Click Here\u00a0to download<\/a>.<\/span><\/span><\/h5>\r\n<\/li>\r\n \t<li>\r\n<h5><span style=\"color: #000000;\">Download the necessary form(s), print it out and fill in the required information.<\/span><\/h5>\r\n<\/li>\r\n \t<li>\r\n<h5><span style=\"color: #000000;\">Fax us your completed form(s) or bring them with you to your appointment.<\/span><\/h5>\r\n<h5><span style=\"color: #000000;\"><strong>Our fax is (815) 233-3379<\/strong><\/span><\/h5>\r\n<\/li>\r\n<\/ul>\r\n&nbsp;\r\n<h4 style=\"text-align: center;\"><span style=\"color: #000000;\"><em><strong>New Patient Health History \/ HIPPA \/ Insurance Forms &#8211; <span style=\"text-decoration: underline;\">Required<\/span><\/strong><\/em><\/span><\/h4>\r\n&nbsp;\r\n<h5><span style=\"color: #000000;\">This lets us know the history and current state of your health. What questions, concerns, goals, regarding\u00a0wellness can we help you with? Let us know!<\/span><\/h5>\r\n[\/vc_column_text][vc_row_inner][vc_column_inner width=&#8221;1\/3&#8243;][vc_custom_heading text=&#8221;New Patient Intake Form&#8221; font_container=&#8221;tag:h5|text_align:left|color:%23dd3333&#8243; link=&#8221;url:https%3A%2F%2Ffreeportfamilychiro.com%2Fwp-content%2Fuploads%2F2022%2F12%2FFFCA_intakeform2022_3.docx|title:New%20Patient%20Intake|target:_blank&#8221;][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;][\/vc_column_inner][vc_column_inner width=&#8221;1\/3&#8243;][vc_custom_heading text=&#8221;HIPPA Form&#8221; font_container=&#8221;tag:h5|text_align:left|color:%23dd3333&#8243; link=&#8221;url:https%3A%2F%2Ffreeportfamilychiro.com%2Fwp-content%2Fuploads%2F2022%2F03%2FPatient-HIPAA-Notice-Consent.docx|title:HIPPA%20Form|target:_blank&#8221;][\/vc_column_inner][\/vc_row_inner]<div class=\"ult-spacer spacer-65cd8bc87d7bc\" data-id=\"65cd8bc87d7bc\" data-height=\"50\" data-height-mobile=\"10\" data-height-tab=\"50\" data-height-tab-portrait=\"50\" data-height-mobile-landscape=\"10\" style=\"clear:both;display:block;\"><\/div>[vc_column_text]\r\n<h4 style=\"text-align: center;\"><span style=\"color: #000000;\"><em><strong>SHAPE ReClaimed Program Form<\/strong><\/em><\/span><\/h4>\r\n[\/vc_column_text][vc_custom_heading text=&#8221;SHAPE ReClaimed Intake&#8221; font_container=&#8221;tag:h5|text_align:center|color:%23dd3333&#8243; link=&#8221;url:https%3A%2F%2Ffreeportfamilychiro.com%2Fwp-content%2Fuploads%2F2022%2F03%2FSHAPE-Intake-Form_V2.docx|target:_blank&#8221;]<div class=\"ult-spacer spacer-65cd8bc87d7f1\" data-id=\"65cd8bc87d7f1\" data-height=\"50\" data-height-mobile=\"10\" data-height-tab=\"50\" data-height-tab-portrait=\"50\" data-height-mobile-landscape=\"10\" style=\"clear:both;display:block;\"><\/div>[\/vc_column][\/vc_row]","protected":false},"excerpt":{"rendered":"[vc_row pix_particles_check=&#8221;&#8221;][vc_column][vc_column_text] Freeport Family Chiropractic &amp; Acupuncture offers our patient form(s) online so they can be completed in the convenience of your own home or office. &nbsp; If you do not already have AdobeReader\u00ae installed on your computer,\u00a0Click Here\u00a0to download&#8230;.","protected":false},"author":7,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v21.9 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Patient Forms - Freeport Family Chiropractic<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Patient Forms - Freeport Family Chiropractic\" \/>\n<meta property=\"og:description\" content=\"[vc_row pix_particles_check=&#8221;&#8221;][vc_column][vc_column_text] Freeport Family Chiropractic &amp; Acupuncture offers our patient form(s) online so they can be completed in the convenience of your own home or office. &nbsp; If you do not already have AdobeReader\u00ae installed on your computer,\u00a0Click Here\u00a0to download....\" \/>\n<meta property=\"og:url\" content=\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/\" \/>\n<meta property=\"og:site_name\" content=\"Freeport Family Chiropractic\" \/>\n<meta property=\"article:publisher\" content=\"https:\/\/www.facebook.com\/Marketing4Wellness\" \/>\n<meta property=\"article:modified_time\" content=\"2022-12-23T16:40:00+00:00\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:site\" content=\"@feedurvitality\" \/>\n<meta name=\"twitter:label1\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data1\" content=\"1 minute\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\/\/schema.org\",\"@graph\":[{\"@type\":\"WebPage\",\"@id\":\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/\",\"url\":\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/\",\"name\":\"Patient Forms - Freeport Family Chiropractic\",\"isPartOf\":{\"@id\":\"https:\/\/freeportfamilychiro.com\/#website\"},\"datePublished\":\"2021-12-20T14:23:11+00:00\",\"dateModified\":\"2022-12-23T16:40:00+00:00\",\"breadcrumb\":{\"@id\":\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/#breadcrumb\"},\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"ReadAction\",\"target\":[\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/\"]}]},{\"@type\":\"BreadcrumbList\",\"@id\":\"https:\/\/freeportfamilychiro.com\/patient-forms-2\/#breadcrumb\",\"itemListElement\":[{\"@type\":\"ListItem\",\"position\":1,\"name\":\"Home\",\"item\":\"https:\/\/freeportfamilychiro.com\/\"},{\"@type\":\"ListItem\",\"position\":2,\"name\":\"Patient Forms\"}]},{\"@type\":\"WebSite\",\"@id\":\"https:\/\/freeportfamilychiro.com\/#website\",\"url\":\"https:\/\/freeportfamilychiro.com\/\",\"name\":\"Ashley Nanney\",\"description\":\"\",\"publisher\":{\"@id\":\"https:\/\/freeportfamilychiro.com\/#organization\"},\"potentialAction\":[{\"@type\":\"SearchAction\",\"target\":{\"@type\":\"EntryPoint\",\"urlTemplate\":\"https:\/\/freeportfamilychiro.com\/?s={search_term_string}\"},\"query-input\":\"required name=search_term_string\"}],\"inLanguage\":\"en-US\"},{\"@type\":\"Organization\",\"@id\":\"https:\/\/freeportfamilychiro.com\/#organization\",\"name\":\"Vitality Consultants LLC \/ AshleyNanney.com\",\"url\":\"https:\/\/freeportfamilychiro.com\/\",\"logo\":{\"@type\":\"ImageObject\",\"inLanguage\":\"en-US\",\"@id\":\"https:\/\/freeportfamilychiro.com\/#\/schema\/logo\/image\/\",\"url\":\"https:\/\/freeportfamilychiro.com\/wp-content\/uploads\/2019\/06\/AshleyNanney-logo-holder.jpeg\",\"contentUrl\":\"https:\/\/freeportfamilychiro.com\/wp-content\/uploads\/2019\/06\/AshleyNanney-logo-holder.jpeg\",\"width\":514,\"height\":98,\"caption\":\"Vitality Consultants LLC \/ AshleyNanney.com\"},\"image\":{\"@id\":\"https:\/\/freeportfamilychiro.com\/#\/schema\/logo\/image\/\"},\"sameAs\":[\"https:\/\/www.facebook.com\/Marketing4Wellness\",\"https:\/\/twitter.com\/feedurvitality\",\"https:\/\/www.instagram.com\/vitality.chef\/\",\"https:\/\/www.linkedin.com\/in\/ashley-nanney-5b20467\/\",\"https:\/\/www.pinterest.com\/VitalityConsultants\/boards\/\"]}]}<\/script>\n<!-- \/ Yoast SEO plugin. -->","yoast_head_json":{"title":"Patient Forms - Freeport Family Chiropractic","robots":{"index":"index","follow":"follow","max-snippet":"max-snippet:-1","max-image-preview":"max-image-preview:large","max-video-preview":"max-video-preview:-1"},"canonical":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/","og_locale":"en_US","og_type":"article","og_title":"Patient Forms - Freeport Family Chiropractic","og_description":"[vc_row pix_particles_check=&#8221;&#8221;][vc_column][vc_column_text] Freeport Family Chiropractic &amp; Acupuncture offers our patient form(s) online so they can be completed in the convenience of your own home or office. &nbsp; If you do not already have AdobeReader\u00ae installed on your computer,\u00a0Click Here\u00a0to download....","og_url":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/","og_site_name":"Freeport Family Chiropractic","article_publisher":"https:\/\/www.facebook.com\/Marketing4Wellness","article_modified_time":"2022-12-23T16:40:00+00:00","twitter_card":"summary_large_image","twitter_site":"@feedurvitality","twitter_misc":{"Est. reading time":"1 minute"},"schema":{"@context":"https:\/\/schema.org","@graph":[{"@type":"WebPage","@id":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/","url":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/","name":"Patient Forms - Freeport Family Chiropractic","isPartOf":{"@id":"https:\/\/freeportfamilychiro.com\/#website"},"datePublished":"2021-12-20T14:23:11+00:00","dateModified":"2022-12-23T16:40:00+00:00","breadcrumb":{"@id":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/#breadcrumb"},"inLanguage":"en-US","potentialAction":[{"@type":"ReadAction","target":["https:\/\/freeportfamilychiro.com\/patient-forms-2\/"]}]},{"@type":"BreadcrumbList","@id":"https:\/\/freeportfamilychiro.com\/patient-forms-2\/#breadcrumb","itemListElement":[{"@type":"ListItem","position":1,"name":"Home","item":"https:\/\/freeportfamilychiro.com\/"},{"@type":"ListItem","position":2,"name":"Patient Forms"}]},{"@type":"WebSite","@id":"https:\/\/freeportfamilychiro.com\/#website","url":"https:\/\/freeportfamilychiro.com\/","name":"Ashley Nanney","description":"","publisher":{"@id":"https:\/\/freeportfamilychiro.com\/#organization"},"potentialAction":[{"@type":"SearchAction","target":{"@type":"EntryPoint","urlTemplate":"https:\/\/freeportfamilychiro.com\/?s={search_term_string}"},"query-input":"required name=search_term_string"}],"inLanguage":"en-US"},{"@type":"Organization","@id":"https:\/\/freeportfamilychiro.com\/#organization","name":"Vitality Consultants LLC \/ AshleyNanney.com","url":"https:\/\/freeportfamilychiro.com\/","logo":{"@type":"ImageObject","inLanguage":"en-US","@id":"https:\/\/freeportfamilychiro.com\/#\/schema\/logo\/image\/","url":"https:\/\/freeportfamilychiro.com\/wp-content\/uploads\/2019\/06\/AshleyNanney-logo-holder.jpeg","contentUrl":"https:\/\/freeportfamilychiro.com\/wp-content\/uploads\/2019\/06\/AshleyNanney-logo-holder.jpeg","width":514,"height":98,"caption":"Vitality Consultants LLC \/ AshleyNanney.com"},"image":{"@id":"https:\/\/freeportfamilychiro.com\/#\/schema\/logo\/image\/"},"sameAs":["https:\/\/www.facebook.com\/Marketing4Wellness","https:\/\/twitter.com\/feedurvitality","https:\/\/www.instagram.com\/vitality.chef\/","https:\/\/www.linkedin.com\/in\/ashley-nanney-5b20467\/","https:\/\/www.pinterest.com\/VitalityConsultants\/boards\/"]}]}},"_links":{"self":[{"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/pages\/226850"}],"collection":[{"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/users\/7"}],"replies":[{"embeddable":true,"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/comments?post=226850"}],"version-history":[{"count":44,"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/pages\/226850\/revisions"}],"predecessor-version":[{"id":226883,"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/pages\/226850\/revisions\/226883"}],"wp:attachment":[{"href":"https:\/\/freeportfamilychiro.com\/wp-json\/wp\/v2\/media?parent=226850"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}