ChiroPlus Complementary Healthcare
Centers, LLC

Last updated 1/30/12

Before your first visit you may be asked to complete some paperwork. Below is a list of forms that Dr. Pomplun’s office may request you to complete. Click on the form to open it in .pdf format and then print on your printer, to complete at home and bring with you to your appointment.

New Patient Forms

A. Insurance or Cash

B. Automobile Accident

C. Workers Compensation

Additional Forms

1. Returning Patient
2. Minor Consent
3. United Healthcare Pre-Authorization
4. CCWI Preauthorization
5. Authorization for Disclosure of Health Information
6. PGIC
7. PSFS
8. Quadruple Visual Analogue Scale
9. Revised Bournemouth Questionnaire
10. Lower Extremity Functional Scale
11. Upper Extremity Functional Scale
12. Workers Compensation Form
13. Automobile Accident Questionnaire
14. Health Questionnaire
15. Detox Questionnaire
16. Diet Diary
17. Notice of Privacy Practices
18. Neuro Spine Referral
19. Generic Referral