WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

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


 


ADDITIONAL FORMS

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 Questionnaire To be completed by patients with neck pain - ONLY when requested by our office.


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online!  We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form

Download the Free AdobeReader®

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

Serving Your Community for 30 Years

1987-2017

THIS ---->https://holistic-chiro.com/online-forms.html

Office Hours

Day
Monday8:30am6:00pm
TuesdayClosedClosed
Wednesday8:30am6:00pm
Thursday8:00am2:00pm
Friday8:30am6:00pm
Saturday8:00am12:00pm
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30am Closed 8:30am 8:00am 8:30am 8:00am Closed
6:00pm Closed 6:00pm 2:00pm 6:00pm 12:00pm Closed

Testimonial

I have found everyone in the office so kind, knowledgeable and flexible. I would definitely feel comfortable referring others to this office.

Newsletter Sign Up