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
Therapeutic Exercise History Form