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100 Year Lifestyle Chiropractor in Cary NC • Phone: 919-461-3933
Make Your Health a Priority!

Patient Forms

We offer our patients form(s) online so you can complete it in the convenience of your own home or office.

Click the link New Patient Online Form below, fill out the form completely and leave no blanks, digitally sign and click submit. Forms will automatically be sent to us and uploaded in our software. (Scroll to the bottom of the forms page to be sure that you can sign forms digitally from your computer. If not, you will not be able to complete the process online and will need to complete the forms in the office)

New Patient Online Form

Patient Information Form

The Patient Information Form is for all patients age 16 and over.

Pediatric Form

The Pediatrics Form is for all patients under 16.

Records Release Form

This form is used when you need to have your private health records released.

Accident History Form

The Accident History Form is for all patients coming in as a result of injuries sustained in an automobile accident.

Three Insurance Form

The Three Insurance Form is also for patients coming in from an automobile accident.