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Smith Chiropractic 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 your printed and completed form(s) or bring it with you to your appointment.

A. Application for Care-History (Day-1) (6)

Download & Print Form


B. ADL-Symptom-Medications (Day-1) (4)

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C. QVAS

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D. Informed Consent (Day-1) (4)

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E. Notice of Privacy Practice (Day-1) (4)

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F. Simple Release - HIPAA Release of Information (5)

Download & Print Form


Intermediate Application for Care (4)

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Pediatric History (Day 1)

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THIS ---->https://lansingleavenworthchiropractorcom.chiromatrixbase.com/new-patient-center/online-forms.html

Testimonial

We value our patients' experience at Smith Chiropractic. If you are currently a patient, please feel free to complete the following Client Experience Questionnaire. The Questionnaire is in Adobe Acrobat format, and requires the free Acrobat Reader to view.
Download & Print Questionnaire

Dr. Ryan Smith
Lansing, KS

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