If you are seeing our Nurse Practitioner or Physician please complete forms 1-3.

If you you are seeing our Chiropractor please complete forms 1-4.

Please print and complete form 5 if you would like to request records from our clinic or from your previous provider.

1. Patient Demographic      PDF | DOC
2. Health History                PDF | DOC
3. Privacy Policy                PDF | DOC
4. Chiropractic Consent      PDF | DOC
5. Records Request            PDF | DOC

 

Pearl Health Center Prepaid Insurance Plan