Online Forms

New Patient Form


Welcome! If you are planning your first visit to Affordable Chiropractic, we look forward to meeting you! To save time on your first visit, we encourage you to download, print, and fill out our new patient forms below.

If you do not already have AdobeReader® installed on your computer, Click Here to download it now.

  • Download the necessary form(s), print it out and fill in the required information.

  • Complete your forms and bring them in with you to your appointment
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Application For Care

Marital Status

Smoking

Current Smoker

Who may we thank for referring you to our office?

Name of primary Care Doctor & Clinic Location

May we send a report of your care to his/her office ?

Describe your major complaint today

When did it start?

Have you lost work days?

If yes, How many?

Have you had this similar condition before?

If yes, When?

General Health History

Have you been treated for any health condition by a physician in the last year?

If yes, Explain

Have you previously received chiropractic treatment?

If yes, list dates consulted and for what problems:

When was your last visit ? Give approximate date

Where you given any exercises to help stabilize or strenghten your spine?

Can you demonstrate these exercises?

Are you currently pregnant ?

Check off the drugs you are now taking:

Other please list:

Have you ever been in an automobile accident?

List the approximate dates of any operations, serious accidents, or unusual diseases, you have had (include any broken bones):

admin none 9:00 AM-6:00 PM 9:00 AM-6:00 PM 9:00 AM-6:00 PM 9:00 AM-6:00 PM 9:00 AM-12:00 PM By Appointment Only By Appointment Only chiropractor # # #