WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Call Us Today

714-963-7432
m

Contact Us Today!

New Patients Are Always Welcome!

Call us at (714) 963-7432 or fill out the form below to request an appointment today. For our Fastest response, please call us and leave a voicemail if we are not in the office, and we will answer all questions the best we can.

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

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

Please fill out ONE of the following Health History forms that pertain to you.  This lets us know the history and current state of your health. Here you will include any questions, concerns, and goals regarding wellness that you would like us to help you with. 

New Patient Health History Form - Required

Download, print and fill out this form if you are a patient without insurance, part of our military discount program, or your insurance coverage is through anyone BESIDES American Specialties Health.

Clinical Submissions Form - Required

Download and fill out the patient information sections if your insurance carrier is through United Health Care

ASH New Patient Health History Form - Required

Download, print and fill out this form, if you have an insurance through American Specialties Health Plan.


ALL future patients please download, print and fill out these forms.

Office Policy - Required 

Welcome to Our Family - Required

Acknowledgment of Receipt HIPPA - Required

Consent to Treatment of a Minor - Required if Patient is Under 18 Years of Age


PI Automobile Accident Forms

Please fill out all of the forms above (EXCEPT the "Welcome to our family" form), as well as the forms listed below:

PI FORMS - Required

*If in an auto accident, it is important to be aware that this office does NOT bill third parties* we will happily bill your auto insurance and/or medpay. 


Workers Comp Patients

Forms will be available in office only. Please allow yourself enough time to fill each form out as accurately as possible. and bring as much information regarding your claim as possible to help the process go efficiently. 

 If it is a workers comp case referrals and authorizations will be required before treatment.

Download the Free AdobeReader®

Links

Conditions Treated
We strive to provide complete care for our patients. Learn more about all the services we provide.
Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.