Online Patient Forms

Modern Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office before you even arrive at our chiropractic office.

  • 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.

Online Patient Intake Form

Please click here to submit your information prior to your visit

New Patient Health History 

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!

 A. Application For Care - Required

Download & Print Form

B. Activities - Symptoms - Medications - Required

Download & Print Form

Notice of Privacy Practices - Required

Download & Print Form 

For Our Pediatric Patients

Pediatric History - Required

Download & Print Form


 For our Weight Loss Patients

 Weight Loss New Patient Intake Form - Required

Download & Print Form

Ask us

Feel free to email us regarding any scheduling or general questions!

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Shane Smith, DC
2301 Berlin Turnpike
Newington, CT 06111