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
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
RemedyTesting - Initial Intake
RemedyTesting - Follow Up
RemedyTesting - Pet Intake
RemedyTesting - Sample Report
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
