Online Forms

Tackett Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.

Please Request An Appointment Before Filling Out The New Patient Health History Form.

Click Here to Request An Appointment

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Patient Demographics

Emergency Contact

Patient Condition

Chief Complaint (Indicate if you have had any of the following):*
Please select at least one option
Mode of Onset:*
Please select at least one option
Relation to other body systems:*
Please select at least one option
Relieving Factors:*
Please select at least one option

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

Draw over image
Type of pain / Where on the body?*
Please select at least one option
Aggravating Factors:*
Please select at least one option
Any diagnostic testing?
Please mark any boxes to indicate you have had the following:*
Please select at least one option

Patient Consent Form (H.I.P.A.A)

Period covering January 1, 2022, to December 31, 2022

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 (H.I.P.A.A). 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 payers (e.g.) 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 H.I.P.A.A. I understand that you reserve the right to change the terms of this notice from time to time and that I may 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 health care 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, 2022, to December 31, 2022

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 this 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 care 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 time frame 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.

Contact Us

We look forward to hearing from you

Office Hours

Our Regular Schedule

Tackett Chiropractic


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

2:00 pm-5:00 pm


9:00 am-12:00 pm

2:00 pm-6:00 pm


8:00 am-12:00 pm


By Appointment Only




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See what people have to say

  • "Such a friendly staff and great chiropractors. Knowledgeable and take the time to make you comfortable! I have been going there for years."
    Erica P.
  • "Always helpful. They inquire about my symptoms and never just squeeze you through a quick pop and some stim. They take time with every patient."
    Eric L.
  • "Awesome service - I could barely walk when I went in and in 20 short minutes I was back to 90% - 1 week later I was back to normal. Friendly, polite, knowledgable and quick - 10 out of 10"
    Brett B.
  • "The staff is amazing! My son also gets adjusted and loves it there. He hasn’t had an ear infection in 1 1/2 years since he started going at 6 months. I’ve had chronic migraines and back & neck pain for years with no relief till I went there. I highly recommend them."
    Casey S.

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