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!

Download & Print Form

Welcome Form

Provides patient demographic information, emergency contact information, insurance information and office financial policy information.

Download & Print Form

HIPPA Form

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.

Download & Print Form

Medical Information Release Form

Used for patient to authorize the release of their medical information such as x-rays, history, diagnosis and treatment.

Download & Print Form

Health Intake Form with Consent Form

Download & Print Form

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