Online Forms

Family Chiropractic Center offers our patient form(s) online so you can complete 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.

Patient Intake Form - Required

This lists basic contact information of our patients including name, address, and phone number.  It also lists some information about our patients lives to provide insight to what may contribute to their injury.  It also includes areas of concern.

Download & Print Form

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! 

Download and Print Form

Family Health History - Required

This lists problems your family members have encountered that might be inherited by you as well.

Download & Print Form

Consent For Treatment - Required

This authorizes the Family Chiropractic Center of Cottage Grove to administer treatment to you, and makes sure you are aware of certain things.

Download & Print Form

Patient Privacy Notice - Required

This notifies our patients of our legal duties to provide private care.  It also asks if you would like to receive a copy of our orivacy copy.

Download & Print Form

Systems Review Form - Optional

This form lists many issues that could signal problems in your spinal alignment, and common symptoms that could affect your condition.

Download & Print Form

 ACH Form - Optional

This form is necessary for patients who wish to make the financial portion of their visit easier with automated payments from their checking or savings accounts.

 COMING SOON for download

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