200 East Lanier Ave. Hwy 54

Fayetteville, GA 30214 US

770-461-8781

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Online Forms

Rasmussen Chiropractic Center for Wellness

Rasmussen Chiropractic Center for Wellness offers our New Patient Forms online so that you are able to print and complete all the necessary paperwork in the convenience of your own home prior to your appointment.

If these completed forms are NOT received by our office prior to or at the time of your appointment, you will need to arrive 30 minutes prior to your appointment time to complete these forms.

  1. If you do not already have AdobeReader® installed on your computer, Click Here to download.
  2. Download/print all the necessary forms to fill in the required information.
  3. Fax your printed and completed forms back to our office (770-461-5079) or hand-carry them to your appointment.



New Patient Forms -

Click on the links below to download/print each form to complete prior to your appointment. 

Also please remember to bring a list of your current medications and a photo ID with you to your appointment.

1. Confidential Patient Information (2 pages)

2. Patient Consent for Use and/or Disclosure of Protected Health Information

3. Insurance Assignment

4. Direct Payment to Doctor

5. Neck Disability Index

6. Oswestry Low Back Questionnaire

7. For United Healthcare Patients Only

In addition to the above forms; if your appointment is concerning a Personal Injury, please fill out the following forms:

8. Health Reports and Doctor's Lien

9. Automobile Accident Questionnaire (2 pages)

10. Payment concerning Personal Injury



Returning Patient Form -

Click on the link below to download/print the form to complete prior to your appointment.

Also please remember to bring a list of your current medications and a photo ID with you to your appointment.

Welcome Back! It's Been a While Since Your Last Visit



Privacy Policy - Disclosure

We are required by applicable federal law to maintain the privacy of your health information.  We are also required to give you this Notice about our Privacy Practices, our legal duties, and your rights concerning your health information. 

Click to review our Privacy Policy.



Ideal Protein New Patient Forms -

Click on the link below to download/print the form to complete prior to your appointment.

1. Ideal Protein Health Profile 

2. Ideal Protein Patient Agreement for Food Purchases

3. Ideal Protein Informed Consent for Weight Control Program

In addition to the above three Ideal Protein forms, please download the following two forms to complete and bring to your next appointment.

1.Cost vs Value - The Ideal Protein Weight Loss Method

2. Ideal Protein New Patient Questionnaire




Download the Free AdobeReader®

Now accepting new patients!

Office Hours

Monday:

8:30 am - 12:00 pm

2:00 pm - 6:00 pm

Tuesday:

8:30 am - 12:00 pm

2:00 pm - 6:00 pm

Wednesday:

8:30 am - 12:00 pm

2:00 pm - 6:00 pm

Thursday:

Closed

Friday:

8:30 am - 12:00 pm

2:00 pm - 6:00 pm

Saturday:

8:30 am - 12:00 pm

By Appointment Only

Sunday:

Closed

Locations

Testimonials

Reviews By Our Satisfied Patients

  • "Great customer service. The entire staff is awesome. I feel so much better."
    Wayne P. / Facebook Reviews
  • "Both Doctors are awesome!"
    Kelli M. / Facebook Reviews

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