New Patient Form

Name: Healthy Balance Chiropractic & Wellness Center
Address: 14 Lincoln Avenue, Lansdale, PA, 19446, United States
Telephone: 215-855-6154

Please fill out the form below to the best of your knowledge. If you do not want to fill out the form via online, you can download the PDF.

Name*
Home Phone*
Cell Phone
Work Phone
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Birthdate*
Age
Who may we thank for referring you?
Occupation
Employer
Employer Address
Street Address Address Line 2 City State ZIP Code
When was the last time you visited a Chiropractor?*
When was the last time you visited your General Practitioner?*
Health Reasons for consulting our office:*
Have you had similar problem(s) before?*
- Yes
- No
How long? Please explain:
Any family members with similar issues?
Is this the result of an auto or work injury?*
- Yes
- No
If so, when?
Other doctors who have treated this problem?*
Surgeries you had:
Medication(s) you currently take:
Is there any chance you are pregnant?*
- Yes
- No
Have you ever been diagnosed with cancer?*
- Yes
- No
If so, what type?
Do you have health insurance?*
- Yes
- No
Provider Name*
Provider ID Number*
I agree*
- I agree
The above information is true and accurate to the best of my knowledge. My reason for the consultation with the doctor is for evaluation of my physical health and potential for improvement.
Cancelation Policy*
- I agree
Healthy Balance office policy requires that a patient cancel or reschedule their appointment within 12 hours of the appointment time. No show or failure to cancel/reschedule within 12 hours will result in a $50 cash visit charge.
CAPTCHA

New Patient Form

Healthy Balance Chiropractor
& Wellness Center

Dr. Drill Instructor Program

Healthy Balance Chiropractor & Wellness Center

Dr. Drill Instructor Program

Healthy Balance Chiropractor
& Wellness Center