Online Forms

Jeffers Neck & Back Pain Center offers our patient form(s) online so they can be completed 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 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!

New Patient Paperwork
General Pain Index
Motor Vehicle Collision Questionnaire
Auto Accident Mechanism of Injury Form
Neck Index
Back Index
Duties Under Duress Summary
Health and Medical Information Release
Insurance Release and Assigned of Benefit
Informed Consent to Chiropractic Treatment
HIPAA Notice of Privacy Practices
Financial Contract

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New Patients Receive a Free Consultation

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