Online Forms

Action Chiropractic Clinic offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us at (831)426-4854 your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Notice of Privacy Policy - Please review 

This notice describes how health information about you may be used and disclosed and how you can get access to this infomration. 

Download & Print Form

Informed Consent Form  - Required

This form gives your consent to the practice that you're willing to undergo chiropractic procedures. 

Download & Print Form

Assignments of benefits  - Required

This form allows us to receive payments from your insurance companies directly to the doctor.

Download & Print Form

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Sign up using the form below or call (831) 426-0609 to make an appointment.


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