Prolific Chiropractic, PC offers our patient form(s) online so they can be completed in the convenience of your own home or 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.
New Patient Health History Form - Required
This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!
Provides patient demographic information, emergency contact information, insurance information and office financial policy information.
Notice of privacy practice summary -- this summary discloses how health information about you may be used; for treatment, to obtain payment for treatment with your authorization as required, for administrative purposes, and evaluate the quality of care that you receive.
Medical Information Release Form
Used for patient to authorize the release of their medical information such as x-rays, history, diagnosis and treatment.
Health Intake Form with Consent Form