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 either our secure New Patient Intake Online Submission Form, OR the printable New Patient Intake Form which you can complete at home and bring with you at the time of your first visit.  If you choose to print your intake form, rather than submit the secure online form, 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.

• 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. 

REQUIRED FORMS

This online form provides us with your health history and the details of your condition. By using this form you will be able to securely and confidentially submit your information directly into our Electronic Medical Record system so that the doctors can review your case prior to your appointment. New Patient Intake Online Submission Form

OR

This paperwork provides us with your health history and the details of your condition. By using this form instead of the online submission  above, you will be able to print and complete this form to bring with you at the time of your first appointment. New Patient Intake Form.

ADDITIONAL FORMS

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 or 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!  Download & Print Form

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James T. Prado, D.C. ~ Brian J. Baker, D.C.
Southbury Connecticut ~ (203) 264-3583 ~ Contact Us