Portolese Family Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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.

Chiropractic New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Pediatric Intake form  (Age Birth-11 years old)

Car accident or Work related Injury

If you had the unfortunate experience of a Motor Vehicle or Work related injury, please fill out the forms that apply.

Motor Vehicle Form + Health History + Oswestry

Workers Compensation Form + Health History + Oswestry

Acupuncture New Patient Forms

Acupuncture Patient Info + New Patient Questionnaire + HIPPA + Cancellation Policy

Massage Therapy New Patient Forms

Massage Intake form

Holistic Health Coaching Patient Forms

Adult Male, Adult Female, Senior, Male Teen, Female Teen, Child

Reflexology New Patient Forms

Reflexology Intake

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 chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, 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!