Online Forms

The Pomperaug Chiropractic & Holistic Center offers patient forms online so they can be completed in the convenience of your own home or office.  We ask that all new patients print and complete our New Patient Intake Form .  Please print and complete any other forms listed below which apply to you.

• 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.

This paperwork provides us with your health history and information on your condition. (Required)
New Patient Intake Form
For returning patients who have a change in their Health status, Insurance, Address, phone, email, etc.
Patient Update Form
For patients who have been involved in a motor vehicle accident of who have been injured and a potential liability exists.
Auto Accident / Personal Injury Form
To be completed by patients with low back pain when requested by our office.  (upon request)
Low Back Questionnaire
To be completed by patients with neck pain when requested by our office. (upon request)
Neck Pain Questionnaire

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!