3333 Brookview Hills BlvdSuite 101

Winston Salem, NC 27103 US

(336) 773-1177

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Online Forms

Stoetzel Chiropractic Clinic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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.


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? Please print out all the forms associated with your case and have them filled out by your first appointment.  If you are unable to print out the forms ahead of time, please arrive to the clinic up to 30 minutes before your scheduled appointment to fill out the paperwork.

New Patient Intake forms (Cash or Insurance Patients)

informed-consent-form.doc                                                                                                   

1-new-patient-intake-form.doc

signature-on-file.docx

Pain-diagram-in-english.docx

New Personal Injury Intake forms (Motor Vehicle Accident Patients)

new-patient-pi-intake-form.doc                                                                                                          

mechanism-of-injury-form-pi-intake-part-2.doc

assignment-of-benefits.docx

informed-consent-form.doc  

Pain-diagram-in-english.docx

Questionnaires 

Headache

Neck

Back

Lower Back

Roland-Morris

Back Bournemouth

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Office Hours

Monday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Tuesday:

3:00 pm-6:00 pm

Wednesday:

9:00 am-1:00 pm

3:00 pm-6:00 pm

Thursday:

3:00 pm-6:00 pm

Friday:

9:00 am-2:00 pm

Saturday:

Closed

Sunday:

Closed

Location

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