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JayMac Chiropractic
  • Home
  • Services
    • FootLevelers Functional Orthotics
  • About Us
  • Contact Us
  • New Patient
    • What to Expect
    • Patient Forms
    • Insurance & Payment Options
    • Chiropractic Wellness Plan
    • Virtual Office Tour
    • Appointments
  • Reviews
  • Blog
  • Privacy Policy
  • Credit Card on File (CCOF)
  • Health Resources

New Patient Intake Forms​

Intake forms like the ones below are used by the doctors at JayMac Chiropractic to accurately diagnose your condition or chief complaint and then develop effective treatment plans. Please print these forms out and complete in the comfort of your home or office. ​
Adult New Patient Intake Form 
(Adults and Children Age 8+)
Adult New Patient Intake Form
File Size: 715 kb
File Type: pdf
Download File

Pediatric New Patient Intake Form
(Babies and Children to Age 8)
Pediatric New Patient Intake Form
File Size: 745 kb
File Type: pdf
Download File


Minor Consent Form (18 and under) 
​Fill out this consent form if you intend to have your minor child examined or treated without you present.
Minor Consent Form
File Size: 654 kb
File Type: pdf
Download File


Personal or Work Injury Forms

Complete the appropriate Intake Form above and appropriate forms below for Motor Vehicle Accident Injuries, Work Injuries or other Personal Injuries.  
Motor Vehicle Accident Details Form
Please complete form to provide us with details about your accident. 
Motor Vehicle Accident Details
File Size: 590 kb
File Type: pdf
Download File

Accident Claim Information Form
Please complete form to provide details about your claim
Motor Vehicle Accident or Personal Injury Claim Information Form
File Size: 375 kb
File Type: pdf
Download File


Arizona Worker's Compensation Form
Please complete the top portion of this form if you were injured while working and have an open Worker's Comp claim with your employer. 
AZ Workers Comp Form ICA 0102
File Size: 539 kb
File Type: pdf
Download File


Medical Records Release Form
Please complete this form if you were treated by another doctor and would like your records sent to us for review. 
Medical Records Release Form
File Size: 481 kb
File Type: pdf
Download File


In order to view the above files please download Adobe Acrobat Reader or equivalent PDF Reader. 
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Address

​22711 S. Ellsworth Rd
Suite # G106
​Queen Creek, AZ 85142
We are located just south of Founder's Park, immediately behind Serrano's Mexican Restaurant in Queen Creek, AZ. We are in building G, the first building on the left when you pull into the development from Ellsworth. We are on the back side of the building. Look for this flag when you get here and walk half way down the pathway. 
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Office Hours

Monday:  8am - 7pm, *
Tuesday, Wednesday: 8am - 5pm, *
Thursday: 
8am - 7pm, *
Friday: 8am - 12pm
​Saturday/Sunday: Closed​
* Closed daily from 12pm - 1pm for lunch.
Click for holiday hours

Contact Us

Voice/SMS/MMS
(480) 264-6800
Fax
(480) 300-4688
Email
Info@JayMacChiropractic.com

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© 2020 JKM LLC dba JayMac Chiropractic | Best Chiropractor in Queen Creek and San Tan Valley | JayMac Chiropractic
  • Home
  • Services
    • FootLevelers Functional Orthotics
  • About Us
  • Contact Us
  • New Patient
    • What to Expect
    • Patient Forms
    • Insurance & Payment Options
    • Chiropractic Wellness Plan
    • Virtual Office Tour
    • Appointments
  • Reviews
  • Blog
  • Privacy Policy
  • Credit Card on File (CCOF)
  • Health Resources