211 Old Hickory Blvd, Bellevue, TN 37221
(615) 646-5686

New Patient Intakes and Forms

Dixon Center of Chiropractic is happy to provide you with a link, via email, to complete your paperwork online without having to email or print a thing!  We also offer our patient form(s) online so they can be completed it in the convenience of your own home or office. The PDFs below are interactive. You can download them, fill them out and send them back to our office by emailing them to: frontdesk@dixoncenter.com. You may also print them and fill them out to bring them in our office, or you may come in 20 minutes early and fill them out in our lobby.


Your information, your rights, our responsibilities. This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.




Our goal is to provide and maintain a good physician-patient relationship. By informing you in advance of some of our policies, it allows for good communication and enables us to achieve our goals. Please read each section carefully. If you have any questions, please do not hesitate to ask a member of our staff.

  1. We are concerned with protecting your privacy. While the law requires us to give you this disclosure, please understand that we have, and always will, respect the privacy of your health information.
  2. Your health care provider and members of the staff may need to use your name, address, phone number and your clinical records to contact you with appointment reminders, information about treatment alternatives or other health related information that may be of interest to you.
  3. You may restrict the individuals or organizations to which your health care information is released or you may revoke your authorization to us at any time; however, your revocation must be in writing and mailed to us at our office address. We will not be able to honor your revocation request if we have already released your health information before we receive your request to revoke your authorization. In addition, if you were required to give your authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims, unless you have paid your out of pocket costs in full.
  4. Information that we use or disclose based on the authorization you are giving us may be subject to redisclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules. You have the right to refuse to give us this authorization. If you do not give us authorization, it will not affect the treatment we provide to you or the methods we use to obtain reimbursement for your care.
  5. This authorization will expire seven years after the date on which you last received services from us. Ultimately, we want to protect you and your health information as enforced by the Department of Health & Human Services.



We ask that you realize we do not work for an insurance company. We feel that insurance can be a great benefit for many patients, and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge will always be based on your individual needs, not your insurance coverage.

Insurance or Billing Questions?
Need More Info On Your Coverage?
Curious About Payment Plans?
Call or Text Us: 615-646-1003
Email: insurance@dixoncenter.com

Dan E.

First chiropractic experience, I am impressed with everyone there and the level of care and knowledge, great communication skills, feeling confident the treatments are already improving my situation!

Kimberly D

Had no idea these folks provided integrated healthcare! Today was my first visit. My chiropractor of 26 years retired suddenly 2 weeks ago and I have been in debilitating pain from my sciatica since then. The entire staff was kind and helpful, and listened intently to my “pain story.” Dr Diaz was incredible, and I walked out the door with greatly-diminished pain. Excited about my continuing care with them. Praise God!