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New Patient Form

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Dr. Gary T. Scardino | 319 South State Street, Newtown, Pa 18940 | 215-860-7275

Scardino Family Chiropractic Center

Thank you for choosing our practice for your chiropractic needs. Please complete this form in link. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

Patient Information

Name

Date

SS/HIC/Patient ID#:

Address

Street Address

City

State

ZIP Code

Sex:

Male

Female

Date of birth

Email *

Home Phone:

Cell Phone:

Work Phone:

Do you prefer to receive calls at:

Partnered for ____ years

Patient Employer/School:

Occupation:

Employer/School Address:

State

City

Zip Code

Spouse/Parent’s Name:

Employer:

Work Phone:

Whom may we thank for referring you to us?

Person to contact in case of emergency:

Phone:

Responsible Party

Name of the person responsible for this account:

Relationship to Patient:

Phone:

Address:

City:

State:

Zip Code:

Name of Employer:

Work Phone:

Insurance Information (Please bring your insurance card to office)

Name of Insured:

Relationship to Patient:

Birthdate:

Social Security#:

Date Employed:

Name of Employer:

Work Phone:

Address:

City:

State:

Zip:

Insurance Co.:

Group#:

Employer#:

Insurance Co. Address:

City:

State:

Zip:

How much is your deductible?

How much have you used?

Max. annual benefit?

DO YOU HAVE ADDITIONAL INSURANCE?

Yes

No

IF YES, PLEASE COMPLETE THE FOLLOWING:

Name of Insured:

Relationship to Patient:

Birthdate:

Social Security#:

Date Employed:

Name of Employer:

Work Phone:

Address:

City:

State:

Zip:

Insurance Co.:

Insured Phone:

Group#:

Insurance Co. Address:

State:

Zip:

How much is your deductible?

How much have you used?

Max. annual benefit?

Daily Habits

What type of exercise do you perform on a daily basis?

None

Moderate

Heavy

What do your daily work habits include? (ex: sitting, standing, light labor, heavy labor, computer work)

What vitamins do you currently take?

What kind of other nutritional supplements do you take (if any)?

Do you smoke?

Yes

No

How much per day?

How much liquor do you consume on a weekly basis?

How much coffee or caffeinated beverages do you consume on daily basis?

Certification & Assignment

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child ever have a change in health.

I certify that I, and or my dependent(s) have insurance coverage with _________________________name of insurance company and assign directly to Dr. ______________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Gaudian or Personal Representative

Your First Visit to Scardino Family Chiropractic Center

At Scardino Family Chiropractic Center in Newtown, PA, we make your first visit simple, stress-free, and focused entirely on understanding your health needs. Whether you’re seeking relief from pain or looking to achieve long-term wellness, our team is here to guide you every step of the way.

From your first consultation to your customized care plan, every step is designed to help your body heal naturally. Experience the difference in patient-centered chiropractic care that truly prioritizes your well-being.

Our 4 Step New Patient Process

1. Consultation

Your first appointment begins with a warm welcome and a one-on-one consultation with Dr. Gary Scardino. We’ll discuss your health history, lifestyle, and current concerns to understand what’s truly affecting your well-being. This is your time to share your goals and ask questions.

2. Scan & Posture Exam

Next, we perform a comprehensive spinal and posture assessment using advanced scan technology. These scans help us pinpoint areas of stress or imbalance in your nervous system without discomfort or invasive procedures. Understanding your posture and alignment gives us a clearer picture of your overall health.

3. Report of Findings

After reviewing your results, Dr. Scardino explains what we found, what it means for your body, and how chiropractic care can help restore proper function. You’ll get personalized insights into your spine health and the underlying causes of your symptoms just a quick fix.

4. Care Plan

Based on your findings, we’ll recommend a customized care plan designed to help you reach your specific goals, whether that’s pain relief, improved posture, or optimal family wellness. We’ll also discuss scheduling, financial options, and what to expect as you begin care.

What to Expect

Your first visit typically takes 45–60 minutes, allowing plenty of time for your consultation, scan, and evaluation. Follow-up visits are shorter, focused on gentle, precise adjustments to help your body heal naturally.

We recommend wearing comfortable clothing and arriving a few minutes early to relax before your appointment.

Schedule Your First Visit

Take the first step toward a healthier spine and a healthier you.

Click below to schedule your consultation and start your journey with Scardino Family Chiropractic Center today.

Schedule Your First Visit

Your trusted partner in Chiropractic Care, and Rehabilitation. We focus on Healing, Recovery, and Enhancing your well-being every step of the way.

Your trusted partner in physiotherapy, chiropractic care, and rehabilitation. We focus on healing, recovery, and enhancing your well-being every step of the way.

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New Patients

Download New Patient Forms

It’s quick, secure, and ready when you arrive, no printing or downloads needed.

Your First Visit to Scardino Family Chiropractic Center

Our 4 Step New Patient Process

1. Consultation

Your first appointment begins with a warm welcome and a one-on-one consultation with Dr. Gary Scardino. We’ll discuss your health history, lifestyle, and current concerns to understand what’s truly affecting your well-being. This is your time to share your goals and ask questions.

2. Scan & Posture Exam

3. Report of Findings

After reviewing your results, Dr. Scardino explains what we found, what it means for your body, and how chiropractic care can help restore proper function. You’ll get personalized insights into your spine health and the underlying causes of your symptoms just a quick fix.

4. Care Plan

Based on your findings, we’ll recommend a customized care plan designed to help you reach your specific goals, whether that’s pain relief, improved posture, or optimal family wellness. We’ll also discuss scheduling, financial options, and what to expect as you begin care.

What to Expect

Schedule Your First Visit

Take the first step toward a healthier spine and a healthier you.

Click below to schedule your consultation and start your journey with Scardino Family Chiropractic Center today.

Your trusted partner in Chiropractic Care, and Rehabilitation. We focus on Healing, Recovery, and Enhancing your well-being every step of the way.

Your trusted partner in physiotherapy, chiropractic care, and rehabilitation. We focus on healing, recovery, and enhancing your well-being every step of the way.

Links

Contact

Scardino Family Chiropractic Center, 319 South State Street, Newtown, PA 18940

[email protected]

(215) 860-7275

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