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

  • 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.


If you would like to have your insurance verified please click here.

New Patient Health History Forms  (This packet is required for all new patients.) We have them broken down into case types, please choose one of the following packets below.

1.  Cash Patients   Click Here
2.  Insurance/ Major Medical Policies   Click Here
3.  Medicare Patients   Click Here
4.  Auto Accident/Injuries (Non-Workers Compensation)   Click Here


Health Records Release Form

Download & Print Form

Pain Questionnaires Forms 

Download & Print Form

Wellness Analysis Packet

Download & Print Form

Aromatherapy Questionnaire & Ion Cleanse Footbath Release Form

1.  Aromatherapy Questionnaire  Click Here
2.  Ion Cleanse Release Form     Click Here


My Chiropractic Story Form

Download & Print Form

Marketing Packet Handout 

Download & Print Form

Satisfaction Survey Form

Download & Print Form

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! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form


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