New Patient Paperwork

Synergy Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.

  • All forms are PDF files. You will need AdobeReader® to view them.
  • If you do not already have AdobeReader® installed on your computer,
    Click Here to download.
  • Download the necessary form(s), print them out and fill in the required information.
  • Fax us your printed and completed form(s) or bring them with you to your appointment.

If you are a new client, please complete the following forms and bring them to your first therapy session.

New Chiropractic Patient Paperwork

Pediatric Intake Form

Pregnancy Intake Form

Neurofeedback Intake Form

Adult Self Report Scale Symptom Checklist

Child Report Scale Symptom Checklist

Limits of Confidentiality / Cancellation Policy

Terms of Acceptance

If you would like me to coordinate care with another provider (for example, your psychiatrist, primary care physician, etc.), complete this form to authorize release of psychotherapy information:

Authorization to Disclose Information Form

OFFICE HOURS

Hours Are By Appointment Only


Monday
9:00am - 7:00pm


Tuesday
9:00am - 7:00pm


Wednesday
9:00am - 7:00pm


Thursday
9:00am - 7:00pm


Friday
By Appointment


Saturday
By Appointment

Synergy Chiropractic
6250 Orchard Lake Road Suite B
West Bloomfield, MI 48322
(248) 862-2202