Your First Visit, Made Simple

WHAT SHOULD I EXPECT AS
A NEW PATIENT?

1

As a new patient, your first step is simply sharing a bit about yourself. The form below helps us understand your health history, current concerns, and goals so your visit can be focused, comfortable, and personalized from the start.

Learn more about our new patient experience here!

WHY DO I NEED TO FILL OUT
THIS FORM?

2

This form allows our team to prepare for your appointment ahead of time. By reviewing your information in advance, we can spend more time listening, answering questions, and providing care that’s tailored specifically to you.

HOW LONG DOES IT TAKE
TO COMPLETE?

3

Most patients complete the form in about 10–15 minutes. You can fill it out at your own pace, and everything is submitted securely online for your convenience.

WHAT HAPPENS AFTER I
SUBMIT IT?

4

Once your form is submitted, our team will review your information and reach out if anything is needed before your visit. From there, you’ll be all set for your first appointment — no paperwork in the waiting room required.

Brighton Campus Chiropractors, L.L.C.
Dr. Louis Catapano, Dr. Shannon Mest, Dr. Kevin Infantino
2024 W. Henrietta Road, Suite 5B
Rochester, NY 14623
(585) 272-7340
The following information is necessary for our files. Please answer all questions completely.
Personal Information
Employment Information
Insurance Information
Pain Assessment
No PainUnbearable
1
No PainUnbearable
1
No PainUnbearable
1
No PainUnbearable
1
Daily Activity Pain Ratings

Pain Scale: 1 = No Pain,
10 = Extreme Pain

ActivityPain Rating (1-10)
Bending
Sitting to Standing
Stairs
Driving
Household Chores
Lifting
Self Care
Sleeping
Standing in Place
Walking
I clearly understand and I agree that all services rendered me are charged directly to me and that I am personally responsible for payment. I also understand that if I suspend or terminate care any fees for professional services rendered me will be immediately due and payable. If I have an insurance carrier, I understand that I am responsible for any deductible, any portion of the fee the carrier does not pay for, or if there is an unreasonable delay by the carrier or myself, I will be responsible for payment on request by this office. If this account is turned over to a lawyer, collection agency, or to the courts, I further agree to be responsible for the payment of all courts to this office for collection of services, including attorney fees, and the amount due is subject to the highest interest possible in this state.

✓ Form Submitted Successfully

Thank you! Your intake form has been received. We look forward to seeing you at your appointment.

Brighton Campus Chiropractors, LLC — (585) 272-7340