Online Forms

New Patient Online Forms

If you are coming to one of our clinics for the first time, please complete the forms below to save time on your first visit. We look forward to serving you!

Pediatric New Patient Online Form (Newborn - 12 Years Old):  Download & Print Form

Adolescent New Patient Form (13 - 17 Years Old):  Download & Print Form

Adult New Patient Form (18 - 64 Years Old):  Download & Print Form

Medicare New Patient Form (65 + Years Old):  Download & Print Form

As a patient of the IRC Physical Therapy and Chiropractic Clinics, you have certain privacy expectations as well as rights and responsibilities. All of the IRC Physical Therapy and Chiropractic Clinics are fully compliant with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) privacy and security rules for health care providers. The confidentiality of your patient records is of paramount concern to us, and you’ll be asked to review information about how we comply with HIPAA rules and sign a form on your first visit.

Before you begin, do you have these handy?

• Driver’s License
• Insurance Card

YOUR PRIVACY, RIGHTS & RESPONSIBILITIES

• Notice of Privacy Practice
• HIPAA Statement
• Rights and Responsibilities