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Print Forms

Lipkin Chiropractic Clinic of Palm Harbor offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Print the necessary form(s), Complete and DATE for the Date of your appointment.
  • Bring your printed and completed form(s) to your appointment.

INITIAL VISIT Health History Form

For a New Patient (or existing patients last seen over 3 years from last visit)  

Print New Patient / Initial Visit Form 


RE-EXAMINATION - Follow-up Questionnaire (for re-exams to check progress)

Print Re-Exam Form


NECK  INDEX

Print Neck Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your NECK condition affects this activity.  

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of NECK pain.


BACK  INDEX

Print Back Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your BACK condition affects this activity.

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of BACK pain.


ACUPUNCTURE - Intake Form

Print Acupuncture Form


PRE-PARTICIPATION SCHOOL PHYSICALS  

$20 all day, everyday

Print School Physical  (EL2) Form

Please fill out Page 1 and the top of Page 2 prior to examination

Pinellas County Middle School and High School Athletic Programs

FHSAA Pre-participation Physical Evaluation Form EL2 (rev.5/14)

 V70.3 ICD-9-CM


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CONTACT US TODAY

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Location

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Office Hours

Our Regular Schedule

Monday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Tuesday:

Call for Appt

2:45 pm - 6:00 pm

Wednesday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Thursday:

By Appointment

By Appointment

Friday:

8:30 am - 12:00 pm

2:45 pm - 6:00 pm

Saturday:

By Appointment

Closed

Sunday:

Closed

Closed