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Request an Appointment

586-296-6242

Bender Chiropractic Health & Vitality Center 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.

New Patient - (Chiropractic)

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!

1. Download & Print Adult History Form

2. Download & Print Child History Form

3. Download and Print Electronic Health Record

4. Download and Print Informed Consent to Care

5. Download and Print Notice of Privacy Practices and Authorization Form


New Patient - (Nutrition)

6. Download and Print New Patient Introduction Form

7. Download and Print Systems Survey Form

8. Download and Print Toxicity Questionnaire

9. Download and Print 7 Pillars of Health Survey of Body's System

10. Download and Print Adrenal Fatigue Quick Check

11. Download and Print 5 Brain Systems Checklist

12. Download and Print Stress Assess Questionnaire

13. Click here to take an online Wellness Check Questionnaire. PRINT RESULTS WHEN DONE.


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



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