Online Forms

Coast Rehabilitation offers our patient form(s) online so they can be completed it 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.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

ASHP Initial Health Status Form

If your Insurance Company goes through American Specialty Health for your Chiropractic benefits they required that you fill out this form. If you're not sure if your Insurance Company goes through ASHP you can call your Insurance Company directly or you can call us and we can help find out for you. Most Insurance Companies that go through ASHP consist of but not limited to Blue Cross HMO, Blue Shield HMO, Cigna HMO & POS, Health Net HMO, and Kaiser.

Auto Injury Form

This lets us know more detail information regarding your car accident. All the forms may not apply to your case due to going through an attorney, third party insurance or your regular insurance company. You may just fill out the nessesary forms that apply to your case and if you are not sure which forms do apply you can always bring all the forms with you to our office and we'll be more than happy to assist you.

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!