Patient Update

Patient Update Form (not seen in over a year)

If you have not been seen in over a year please fill out this form.

Updated Patient Records- Tackett Chiropractic- 

Over 1 year since last appt.

Patient Condition

Chief complaint*
Please select at least one option
Mode of onset*
Please select at least one option
Please select one option
Relation to other body systems*
Please select at least one option
Relieving factors*
Please select at least one option
Aggravating factors*
Please select at least one option
Type of pain*
Please select at least one option

Please mark or circle areas on the diagram where you experiencing pain, discomfort or are concerned about.

Patient Consent Form HIPAA

Period covering January 1, 2023 to December 31, 2023

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the health insurance portability and accountability act of 1996 (HIPAA). I understand that by signing this consent, I authorize Tackett Chiropractic Center to use and disclose my protected health information to carry out:

  • Treatment, including direct or indirect by other healthcare providers involved in my treatment.
  • Obtaining payment from third-party goers, we will check your insurance policy regarding benefits, claims, and authorizations online or by telephone.

I have also been informed of and given the right to review and secure a copy of my notice of privacy practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I made contact Tackett Chiropractic Center at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and obtaining insurance information online or by telephone from the insurance companies and health and healthcare operations. I understand that Tackett Chiropractic Center is not required to agree to these requested restrictions.  However, if you do agree, you are then bound to comply with the restrictions.

Patient Consent Form (ABN)

ABN Period Covering January 1, 2023 to December 31, 2023

I understand that I may be financially responsible for any charges incurred at this office, including co-pays, deductibles, and charges denied or not covered by my insurance company. I realize my care may be subject to pre-certification by the insurance company and I accept any and all documentation submitted by Tackett Chiropractic for review for medical necessity and base their approval/denial upon the documentation. I understand that this office agrees to notify me as soon as possible if service is not covered and will notify me if my hair is not covered by my insurance company. If a treatment plan is approved, this office will make me aware of the number of office visits allowed at the timeframe of the certification. Initial visits may be denied, and this may be beyond approval. These charges will be the patient's responsibility if denied by the insurance company. This office may seek payment from you for any services your health insurance plan determines to be not medically necessary.

I have read and understand my obligations for payment for care in the absence of insurance coverage.

Thank you for taking the time to fill out this form.


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Office Hours

Our Regular Schedule

Tackett Chiropractic


8:00 am - 12:00 pm

2:00 pm - 5:00 pm


8:00 am - 12:00 pm

2:00 pm - 6:00 pm


8:00 am - 12:00 pm

2:00 pm - 5:00 pm


9:00 am - 12:00 pm

2:00 pm - 6:00 pm


8:00 am - 12:00 pm