Proactive Chiropractic and PT 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 or email us your printed and completed form(s) or bring it with you to your appointment. If you have not completed the necessary forms, please arrive 30 minutes before your appointment time.
- Please note, our office requires 24 hour notice for cancellation or missed appointments. Failure to give notice will incur a fee. This expense cannot be billed to your insurance, personal injury protection or workman's compensation.
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! Please download the forms that apply to which type of provider you will be seeing.
New Patient Paperwork (First-Time Patients)
Re-Evaluation Form - 6 MNTHS/ANNUAL
United Healthcare and Medicare Coverage Forms - *Required*
Some Insurance Providers require additional forms for coverage. If you have United Healthcare and are scheduled with Dr. Pollack, Dr. Dispenza or Dr. Chen you must fill our the United Healthcare Summary Form and one of the forms related to the area of your body related to your condition. If you have Medicare, please fill out the form for the area of your body related to your condition.
United Healthcare Patient Summary Form
Lower Extremity Functional Scale (LEFS)
Arm, Shoulder, or Hand Form (DASH)
Medicare Physical Therapy Questionnaire