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Belmont Chiro
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    • HOME
    • ABOUT
      • Our Office
      • The Team
      • Contact Us
    • SERVICES
      • Chiropractic Services
      • Dry Needling
      • Spinal Decompression
      • Shockwave Therapy
      • Stretch Therapy
    • NEW PATIENTS
      • FAQ
      • Request An Appointment
      • Patient Forms
    • BOOK NOW
Belmont Chiro

Signed in as:

filler@godaddy.com

  • HOME
  • ABOUT
    • Our Office
    • The Team
    • Contact Us
  • SERVICES
    • Chiropractic Services
    • Dry Needling
    • Spinal Decompression
    • Shockwave Therapy
    • Stretch Therapy
  • NEW PATIENTS
    • FAQ
    • Request An Appointment
    • Patient Forms
  • BOOK NOW

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New Patient Forms

All new patients are required to fill out and complete the required intake forms. You may do this directly using our online patient portal, or you may do so using digitally submitted PDF forms.


All new patient forms are available for download. Please completely fill out the forms, and then upload them using the form below to finalize their submission. You may also email them directly to: info@belmontchiroclinic.com. 


If you wish, you may also attach any relevant medical records or imaging reports, including XRAY, MRI, CT, Ultrasound, etc.

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

Intake Document - Submission Form

Please complete the form below and attach your completed intake documents to finalize your submission. Thank you.

Attach Documents
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E: info@belmontchiroclinic.com

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Exciting News! Meet Our New Chiropractor!

We are thrilled to introduce Dr. Alexa Thompson (Dr. T), the newest member of our amazing team!

Dr. T specializes in family wellness, prenatal and postnatal care, bringing a passion for helping moms, babies, and families thrive. Whether you're navigating pregnancy, postpartum recovery, or looking for holistic care for your little ones, Dr. T is here to support you every step of the way.

Join us in giving our new doc a warm welcome! We can’t wait for you to meet her!

BOOK AN APPOINTMENT TODAY