Patient Forms

New Patient Forms

Thank you for choosing Brookview Wellness for your care. Dr. Brooke & Dr. Shelby look forward to meeting you and helping you achieve your best health possible!

CHIROPRACTIC FORMS

Prior to your visit, please fill out the New Patient Intake form ONLINE.

Online New Patient Intake Form

Prior to your visit, please PRINT and complete the following forms. BRING the completed forms to your first appointment. Forms are available at office if needed, please arrive 15 minutes before scheduled appointment time to complete.

Notice of Privacy Form – HIPPA
Direct Assignment of Benefits & Authorization to Release
Patient Financial Policies
Appointment Agreement
Medicare Advance Beneficiary Notification – *Medicare Only
Neck & Back Index – *Medicare Only

FUNCTIONAL MEDICINE / NUTRITION PATIENTS

In addition to the chiropractic forms to the left, please fill out the following forms before your first nutrition appointment. Print and return to the office, via fax 919-577-2226 or email to them to info@brookviewwellness.com prior to your appointment to be reviewed. Include recent lab work within the last year.

Overall Health: Metabolic Assessment
Brain Health & Nutrition Assessment
Brain Function Assessment
Neurotransmitter Assessment
Children’s Neurotransmitter and Nutrition Assessment

MASSAGE THERAPY FORMS

PLEASE NOTE: For your safety we require a note from your primary care provider releasing you for massage if you have any of the following conditions: Any cardiovascular issues, currently receiving chemo or radiation for cancer treatment or history of blood clotting disorders.

Massage Patient Intake Form
Massage Client Policy Notification
HIPPA Compliance Form
Medicare* Advanced Beneficiary Notification
Oncology* Massage Intake
Minor* Massage Release Form

INSURANCE PLANS ACCEPTED

We no longer accept insurance. All our clients are on a cash only basis. We will be glad to work with you so you can submit your claims to your insurance directly.