Forms

New Patient – Chiropractic

Download form (in PDF format) here: New Patient Information Form

New Patient Form – Medical

(Necessary for your appointment with Dr. Dickens)

Download form (in PDF format) here: NP-Questionnaire

**This form needs to be completed prior to seeing Dr. Dickens or Gary Dunaye, P.A. Please bring it with you to your scheduled appointment filled out as thoroughly as possible.

Workers’ Industrial Injury:

Step 1 – Report your industrial injury to your supervisor, prior to scheduling your appointment with our doctors. Make sure you have filled out all the appropriate paperwork required of you by your employer.

Workers’ Compensation Injury Questionnaire

Please fill out this questionnaire and bring it in with you, along with any insurance information you have received from your employer, employer information and phone numbers. Click here to down load a PDF version of the Worker’s Compensation new patient questionnaire.

Neuropathy Relief Care Program

Download form in PDF format here: Neuropathy Admission Application

Notice of Privacy Practice Form

Effective date: September 23, 2013 . This form describes how medical information about you may be used and disclosed and how you can get access to this information. Review carefully.

Download here: HIPAA Privacy Practices