MILLENNIUM CHIROPRACTIC
7177 Brockton Ave #219
Riverside, CA 92506
Tel: 951-323-7783
Fax: 855-293-4899
Massage
Massage
Welcome to Our Online Forms Page
In this section of our website, you will be able to take care of the items necessary for your first chiropractic visit prior to arriving, in the comfort of your own home. You are welcome to print and fill out these forms, and bring them with you, OR You can use the Fill Online Links (Orange) to fill online and submit them directly to our secure system.
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Please do not date your forms since the forms need to have the date of your actual appointment.
If you have any questions at any time, please don't hesitate to contact our office @ 951-323-7783 !
All New Patients INCLUDING Auto Accident Cases PLEASE USE THE FOLLOWING FORMS
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New Patient Intake Forms:
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& Please Read Our Notice of Privacy Practices
All Returning Patients:
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If you haven't been seen in the last 3 months, please fill out this form:
PLUS: (All new and Returning Patients must fill out one or more of the following forms, depending on your complaints. If there is no pain in any of the following parts please skip these forms.
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If you have shoulder, arm, or hand pain Upper Extremity Index
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If you have hip, leg, knee, ankle, or foot pain Lower Extremity Index
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Additional Forms for Specific Insurances
Patients with United Healthcare & Any Plan thru Optum Health must fill out the following 2 forms in addition to Patient intake forms and the Indexes according to your primary complaint. Thank you.
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