Patient Forms
Before receiving care and services at Harmonious Living Chiropractic: Fitness & Wellness Center, there are importnat forms you must complete. Below are common forms used in our office. Download, complete and return the form(s) to our office, if/when requested by a team member.
Our chiropractor in Baltimore, MD offers different types of appointments: +New Patient Appointments (1st Visits)
+Follow-Up Appointments
+House Visits | House Call Appointments
+Telehealth Visits
New Patient Package Forms
Adult: New Patient Package (Non-Medicare)
Adult: New Patient Package (Medicare)
Auto Injury Claim: New Patient Package
Pediatric: New Patient Package
Workers’ Compensation Injury Claim: New Patient Package
Returning Patient Forms
Returning Patient Health Update
Release of Medical Records Forms
Authorization to Release Medical Information/Records
Request Copy of Medical Records Forms
Request Copy of Patient Medical Information/Records
Telehealth Services Forms
Consent to Telehealth Services
Doctor’s Service Forms
Request Doctor to Complete Forms (e.g. FMLA)
Request Doctor for Independent Medical Examination/Impairment Rating
Request Doctor to Review Medical Records/Case (e.g. 2nd Opinion)
Billing and Payment Forms
Request Copy of Patient Bill
Request Payment Plan Request
Request Financial Assistance
Home Visit Forms
Notice for Bringing Others to Your Appointment: If you would like to bring someone with you for your appointment, let us know; so we can make sure we can accommodate.
Treating Minors at Our Office: Harmonious Living Chirorpactic: Fitness & Wellness Center is family-friendly office. We welcome people of all ages to experience chiropractic care. All minor patients must be accomapneid by a parent (or legal guardian) or authoratized personnel for duration of the appointment. No expcetions.
