Patient Forms
Save time at your appointment by downloading and completing your patient forms before your visit. You have two options: print the forms, fill them out, and bring them with you — or scan completed forms and email them to us before your appointment.
Available Forms
Click the download button to save each form to your device
Consent Form
Required consent form for chiropractic treatment.
HIPAA Consent Form
Required authorization for the use and disclosure of your protected health information.
Appointment Policy
Overview of our appointment policies, cancellation procedures, and patient responsibilities.
Treatment Application
Treatment application and medical evaluation form for new patients.
Health History Questionnaire
Detailed health history including past conditions, surgeries, medications, and family medical history.
ADL Functional Rating Index
Functional assessment form to evaluate your activities of daily living.
Health Satisfaction Score
Health satisfaction survey to help us understand your wellness goals.
Pediatric Exam Form
Specialized form for pediatric patients undergoing chiropractic evaluation.
What is Chiropractic Brochure (Outside)
Educational brochure explaining chiropractic care and its benefits.
What is Chiropractic Brochure (Inside)
Educational brochure explaining chiropractic care and its benefits.
How to Submit Your Forms
Bring to Your Visit
Print out all completed forms and bring them with you on the day of your appointment. This allows us to review them in person and answer any questions.
Scan & Email
Scan your completed forms and email them to drmukaia.wellness@gmail.com before your appointment. Please use clear scans and include your name in the email subject line.
Ready to Schedule Your Visit?
Once you've downloaded and completed your forms, give us a call or book online to schedule your appointment.