Online Forms
Cira Family Chiropractic offers our new patient forms online so you can complete them in the convenience of your own home or office. If you have any questions about the required information, please do not hesitate to contact us at 650-508-9111.
- If you do not already have AdobeReader® installed on your computer, Click Here to download.
- Download the necessary forms, print it out and fill in the required information.
- Fax us your printed and completed forms or bring it with you to your appointment.
- Acknowledgement and Understanding
- Individual Patient's Authorization
- Case History Form
- Notice of Privacy Practices - Information
- Notice of Privacy Practices – Acknowledgement Form
- Office Financial Policy and Agreement
- [1] Patient Health Questionnaire
- [2] General Pain Index Questionnaire
- [2]Headache Pain Disability Index
- [2]Neck Pain Disability Index
- [2]Low-Back Pain Disability Index
Depending on the type of injury and the medical coverage, further forms may be required. Minors require special forms available from the doctor's office.
[1] Blue Shield Only
[2] Use only one of these for the type of pain being experienced. General Pain Index is used for hands, feet, mid-back, and any other extremities. The other pain indices are to be used for the specific pain as noted (e.g. Neck Pain Disability for all neck pain)
3D Spine Simulator
Launch 3D Spine Simulator