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Home > New Patient Center > Online Forms

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)

Download & Print Form

C. QVAS

Download & Print Form

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

Download & Print Form

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

Download & Print Form

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

Download & Print Form

Intermediate Application for Care (4)

Download & Print Form

Pediatric History (Day 1)

Download & Print Form


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

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Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.

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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