Online Forms
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 complete our New Patient Intake Form which you can complete at home and bring with you at the time of your first visit. Don't forget to bring it with you on your first visit! Additionally we ask that you please print and complete any other forms listed below which apply to you.
Dr. Kauffmann's intake forms for Naturopathy/Acupuncture, Homeopathy and Psychology are also available below.
- 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.
Dr. Prado & Dr Baker's New Patient Intake Form
Dr. Kauffmann's Intake Forms:
Please print the appropriate form(s) and bring them with you on your initial visit.
Naturopathic & Acupuncture Intake Form
Patient Update Form For returning patients who have a change in their Health status, Insurance, Address, phone, email, etc.
Auto Accident / Personal Injury Form For patients who have been involved in a motor vehicle accident or who have been injured and a potential liability exists.
Low Back Questionnaire To be completed by patients with low back pain - ONLY when requested by our office.
Neck Pain Questionnaire To be completed by patients with neck pain - ONLY when requested by our office.
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! Download & Print Form
Download the Free AdobeReader®
James T. Prado, D.C. ~ Brian J. Baker, D.C.
Michaela Kauffmann, ND, PsyD, LAc
Southbury Connecticut ~ (203) 264-3583 ~ Contact Us