Online Forms

Action Chiropractic & Rehab understands your time is valuble, which is why we provide online patient forms, from which new patients and current patients can print and fill-out at home, saving you time by having your paperwork ready on the date of your appointment.

1. Click the link next to the form(s) you need to complete in order to view the document.
2. Select the print icon from the top left side of the page.
3. Fax your printed and completed form(s) or bring the form(s) in person on your visit.

The fax number for our Mesa chiropractic center is 480-635-1719, and the fax number for our Gilbert chiropractic center is 480-821-6326.

Health History Form for New Patients – View & Print
Health History Form for New Patients (Spanish) – View & Print

We ask that all of our new patients complete the above form prior to your initial consultation. If you have any questions or concerns regarding your current physical health and our treatment procedures, please feel free to contact us.

Auto Injury Patient Form – View & Print
Auto Injury Patient Form (Spanish) – View & Print

If you have been in an automotive accident, and intend to visit Action Chiropractic & Rehab for physical rehabilitation, we ask that you fill out the above form prior to your initial consultation. If you have any questions or concerns regarding your current physical health and our treatment procedures, please feel free to contact us.

Case History Update – View & Print

Consent to Treat a Minor – View & Print

Neck Pain Questionnaire – View & Print

Roland Morris Low Back Questionnaire – View & Print

Oswestry Low Back Questionnaire – View & Print