Online Forms

Smithtown Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.

FOR CHIROPRACTIC PATIENTS

  • Please complete the Online Forms and submit to our office

PERSONAL HISTORY

PATIENT HEALTH QUESTIONNAIRE

ASSIGNMENT & INSTRUCTION FOR DIRECT PAYMENT TO DOCTOR

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM

UNITED HEALTHCARE/NYSHIP PATIENT AUTHORIZATION FORMS


FOR PHYSICAL THERAPY PATIENTS

The forms below can be printed out at home and brought in our office

PERSONAL HISTORY

PATIENT HEALTH QUESTIONNAIRE


The forms below can be printed out at home and brought in on your first visit

  • 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.
  • Bring your completed forms with you to your appointment.

New Workers Compensation Patient Forms (for new patients who also have a workers comp injury)

New No Fault Patient Forms  (for new patients who also have a no fault injury)

Nutrition New Patient Intake Form

Nutrition Follow Up Form

Massage Therapy History Form

Therapeutic Exercise History Form




Download the Free Adobe Reader®

Contact Us

We look forward to hearing from you! One of our staff members will get back to you during our regular business hours.

Location

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Office Hours

Our Regular Schedule

Smithtown Chiropractic

Monday:

9:00 am-8:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

9:00 am-8:00 pm

Thursday:

Closed

Friday:

9:00 am-8:00 pm

Saturday:

9:00 am-12:00 pm

Sunday:

Closed