Accessibility View Close toolbar

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.

  • 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.

Our New Patient Intake Form


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.

Download the Free AdobeReader®

James T. Prado, D.C. ~ Charles W. Benson, D.C.
Southbury Connecticut ~ (203) 264-3583 ~
Contact Us


Office Hours

Primary Location


8:30 am-6:00 pm




8:30 am-6:00 pm


8:00 am-2:00 pm


8:30 am-6:00 pm


8:00 am-12:00 pm




  • "I have found everyone in the office so kind, knowledgeable and flexible. I would definitely feel comfortable referring others to this office."
  • ""Dr. Benson is absolutely wonderful. I started seeing him at the very end of my pregnancy for back pain. Due to carrying a very large baby, as well as, hoping to aid in opening my pelvis in order to get labor going. Just 2 hours after my second visit early labor had begun and days later our little boy was born. I look forward to returning!!""
  • ""There is no one better than Dr. Pardo, take it from someone who moved out of the state and has never found anyone like him. We miss you Jim! ""