Scituate Harbor Chiropractic Forms

Welcome to the Scituate Harbor Chiropractic (SHC) Forms page. Below you will find an assortment of categorized forms readily available for you to download, print and complete. A short description is included below each form title, along with the file size. All the forms are formatted as a PDF and require Adobe Reader to view. Should you need the Reader program, a free and easy to install download is available for the PC or Mac operating system, simply click here.

If you're a new member to SHC and want to complete the paperwork prior to your appointment, forms 1 through 4 need to be completed and brought with you. Thank you for preparing ahead of you scheduled appointment!

Other forms may be required after your first visit.

New Member Forms

1) Welcome to Scituate Harbor Chiropractic (76k, PDF)
Welcome to Scituate Harbor Chiropractic. Step One: About You…

2) Family Health History (92k, PDF)
If you or members of your family have experienced any of the following…

3) Initial New Member Survey ( 96k, PDF)
It is our goal to fully understand your needs and wants regarding…

4) Privacy Notice (108k, PDF)
This Notice Describes How Chiropractic and Medical Information…

5) Automotive Accident (108k, PDF)
Please take a moment to complete all the questions regarding your accident…

6) Your Testimonial (64k, PDF)
Dear friend and member, you now have a story that needs to be…

SHC Policy Forms

7) Insurance Assignment Policy Statement (96k, PDF)
You have selected to use your insurance benefits to assist in your…

8) Authorization and Assignment (100k, PDF)
In consideration of your undertaking to treat me, I agree to the following…

9) Automotive Accident (108k, PDF)
Please take a moment to complete all the questions regarding your accident…

10) Auto / Personal Injury Protection (PIP) Accident Policy (100k, PDF)
In those states with no-fault insurance, persons involved in an auto accident…

Financial Forms

11) Financial Policy (104k)
For our members without insurance coverage. We believe a clear understanding…

12) Financial Policy Workers Comp ( 96k)
Your worker’s compensation insurance through your employer will normally…