Intake Forms

For your convenience, Rocky Mountain Chiropractic & Sports Injury Centers now offers our intake forms online. Please fill out the following forms. All patient must fill out the RMCSIC Intake Form. It is best if you have it filled out when you get here, but you are welcome to fill it out in our office. Please remember to bring it to your initial visit.

RMCSIC Intake Form (all patients)

Privacy Policy (Not available on-line)

Consent to Treat a Minor (Not available on-line)

United Health Care and Great West Patients Only
ACN Intake Form (all patients on United or Great West Insurance)
Neck Pain Index (all patients on United or Great West Insurance)
Back Pain Index (all patients on United or Great West Insurance)

Sports Physical Forms
CHSAA General Form
All athletes must filled out Parts I & II of the CHSAA General Form. Your school may have a form of it’s own, please bring it with you. If your form does not contain a health history comparable to the one in Part II of the CHSAA form, we will need to have you fill out the health history on the CHSAA form. This is needed to conduct your evaluation. Please note that there are two columns to the health history. If you have any questions, we will be happy to assist you. We do have copies of the CHSAA form and the Windsor/Severance Middle School form one hand if you don’t fill one out in advance. WHS students only need the CHSAA form.