New Patient Paperwork

The New Patient Forms take an estimated 10-15 minutes to complete, unless you have a detailed health history. The forms are not always compatible with Internet Explorer. These forms are best completed on a desktop or laptop computer. You may experience problems submitting the forms if completed on a tablet or smartphone. Please fill out the forms using a different browser.

  • If you are 65 or older or have Medicare, please email our new patient coordinator at BEFORE filling out the online New Patient Forms. In your email, please include your name and best telephone number to reach you. We will contact you regarding Medicare and our 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.

At Chiropractic Health And Wellness Center, your first visit will begin with a warm smile and personal greeting! If you would like to come to our office as a new patient, please fill out the New Patient Forms.

These forms are our first insight to your overall health and spinal condition and are vital for initiating your care. Please provide us with the best phone numbers and contact information. We ask that you plan to be in our office a total of two hours for your first in office visit.

Please be aware that you will not be contacted to schedule your new patient appointment unless we receive your completed New Patient Forms. This occurs when you click the “SUBMIT” button at the end of the New Patient Forms. Please be sure to fill out your insurance information on the paperwork as well. Once you submit your forms, our New Patient Coordinator will call you, usually within 24 business hours, to discuss your insurance benefits and schedule your first appointment.

  • New Patient Form

    Click to Complete

  • HIPPA - Read Only

    Click to Read


7:30am - 12:30pm
2:00pm - 6:00pm

1:30pm - 6:00pm

7:30am - 12:30pm
2:00pm - 6:00pm

1:30pm - 6:00pm

7:30am - 12:00pm

Saturday & Sunday

Chiropractic Health and Wellness Center

5412 Glenside Dr Suite E
Richmond, VA 23228

(804) 359-6999