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.
- 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.
Update Patient Intake 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 QuestionnaireTo be completed by patients with neck pain - ONLY when requested by our office.
James T. Prado, D.C. ~ Charles W. Benson, D.C.
Southbury Connecticut ~ (203) 264-3583 ~ Contact Us