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All patient forms can be downloaded via the links provided further down this page.

All new patients are required to complete and submit the following forms:

New Patient Intake Form
Past Medical History
Chief Complaint Form
HIPPA Compliance Form
COVID-19 Questionnaire

Some additional forms may be required. Please complete and submit any of the forms below that may apply:

Pregnancy Questionnaire
General Health Update (Previous patients who have not been see at our office in over 1 year)
Consent to Treat a Minor (Patients under 17 years old)
Motor Vehicle Accident Questionnaire

New Patient Forms

Please download and complete the applicable forms from the list below. Upon completion, you may either submit them via the form above, or via email attachment to: Email: belmont.chiro.clinic@gmail.com. Please include any additional relevant medical notes or documents.

Patient Intake Form (pdf)Download

Past Medical History (pdf)Download

History of Chief Complaint (pdf)Download

HIPAA (pdf)Download

COVID-19 Questionnaire (pdf)Download

Pregnancy Questionnaire (If Applicable) (pdf)Download

General Health Update (Established patients, who haven't been seen in a period >1 year) (pdf)Download

Minor Consent Form (If Applicable) (pdf)Download

MVA Questionnaire (If Applicable) (pdf)Download

Spinal Decompression Therapy Now Available!

It is finally here! Our Spinal Decompression Therapy table has arrived!

If you suffer from disc-related back pain, spinal stenosis, facet syndromes, or many other conditions, you may be a candidate for this treatment option.

If you are interested, please fill out our pre-registration survey!

Take Survey