Back to Wellness Clinic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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.
Health History Forms - Required for all chiropractic and massage therapy patients
This lets us know the history and current state of your health.
New Patient
Chiropractic New Patient Paperwork
If the chiropractic patient is 6 years old or younger, please use this Pediatric Form in place of the New Patient Paperwork.
If the chiropractic patient is 17 years old or younger, please use this Consent for Treatment of a Minor Form along with the New Patient Paperwork.
If the patient is seeking care due to an auto accident, please fill out this Auto Accident Questionnaire along with the New Patient Paperwork.
Returning Patient
Patient Acknowledgement of HIPAA Notice
Authorization to Release Protected Health Information
Acupuncture Intake form - Required for acupuncture patients only
This form allows our acupuncturist, Dr. Viviana Viera, to know the history and current state of your health, along with any questions, concerns and goals regarding your acupuncture visit.