Client Forms

Most of Dr. Dane's client forms can be downloaded and printed with the links below.

While you're here, please enjoy the Featured Healing Image at the bottom of this page!

Click here if you hate to fill out forms angry

To Print: click on the link for the appropriate form and a PDF file will open up. Click on the little "printer icon" at the far left of the tool bar, just above the upper left corner of the page. This will open your printer window.

To save to your computer: click on the “floppy disk” icon next to the printer icon mentioned above. Then, from the window that appears, choose the location on your computer that you would like to save it to. You can make a folder to hold educational articles, MP3's and forms from our practice.

If you can't print with the computer you’re using, you can come early to your appointment and fill the forms out then. Please let us know beforehand so we can have the forms ready for you in the waiting area.

For Most New Clients – please print & fill out both of these forms:
New Client Information
Chief Concern

For Clients who intend only one or two "patch-me-up" visits – please print & fill out this short form: New Client Information – Short Form

For All Adults: Informed Consent

For All Kids under 18: Consent to Treat Minor

Specialty Questionnaires
Depending on your situation, we may ask you to complete an additional questionnaire or two. This will help us create the best treatment approach for you right from the start.

Allergy Symptom Checklist

Auto Accident

Scars & Trauma


Ick – I hate forms!

Most of us don’t care to fill out “yet another form.”  We know – we don’t like them either.  And there are some great benefits to completing our forms:

  1. It saves us time, and saves you money.  The information given allows us to see a “bigger picture” of your health, and still focus on your chief concerns.
  2. It aids our detective work and  allows us to address your main concerns more effectively.  We often find clues as to why those symptoms are there in the first place, so we can address the underlying causes.
  3. This information often helps us spot potential problems before they become apparent.  An “ounce of prevention” is “worth it’s weight in gold” (which is about $1200 an ounce these days)! Catching something early will save you time, inconvenience, discomfort and money later on.
  4. It keeps us legal – we're required to gather relevant history information as part of your records.

If you are having trouble filling out your form, you could hang out with the image below for a few minutes. Then it might be easier to complete the info sheet.


Upper McKenzie River, Oregon,  by Dr Dane

Upper McKenzie River, Oregon, by Dr Dane