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Online Forms

Bender Chiropractic Health & Vitality Center 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.

New Patient - (Chiropractic)

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!

1. Download & Print Adult History Form

2. Download & Print Child History Form

3. Download and Print Electronic Health Record

4. Download and Print Informed Consent to Care

5. Download and Print Notice of Privacy Practices and Authorization Form


New Patient - (Nutrition)

6. Download and Print New Patient Introduction Form

7. Download and Print Systems Survey Form

8. Download and Print Toxicity Questionnaire

9. Download and Print 7 Pillars of Health Survey of Body's System

10. Download and Print Adrenal Fatigue Quick Check

11. Download and Print 5 Brain Systems Checklist

12. Download and Print Stress Assess Questionnaire

13. Click here to take an online Wellness Check Questionnaire. PRINT RESULTS WHEN DONE.



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Locations

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Office Hours

Our Regular Schedule

Harper Avenue

Monday:

9:00am - 1:00pm

3:00pm - 6:00pm

Tuesday:

Closed

3:00pm - 7:00pm

Wednesday:

9:00am - 1:00pm

3:00pm - 7:00pm

Thursday:

10:00am - 1:00pm

3:00pm - 7:00pm

Friday:

8:00am - 12:00pm

Closed

Saturday:

Closed

Closed

Sunday:

Closed

Closed

CONTACT US TODAY

We look forward to hearing from you