Patient Forms

Forms for chiropractic patients of Pearson Chiropractic.

Download forms here or pick them up
at the chiropractic office.

Save Time
If you’d like to save time at your first appointment please print, fill out and bring your forms with you. If you prefer to fill out the forms at our office please arrive 15 minutes before your appointment time. We’ll provide the forms you need when you arrive.

Every New Patient Fill out both the Patient Information and the History Checklist. You may want to read the Financial Policy before your first visit.
•	Financial Policy
•	History Checklist
•	Patient Health Information Consent Form
•	Patient Information

On-The-Job Injuries Fill out this form if your injury happened on-the-job.
•	Workers Compensation History

Injuries Related to Auto Accidents Fill out both of these forms if your injury was caused by an automobile car accident.
•	Auto Insurance Form
•	Personal Injury Questionnaire

Doctor Instructions
•	Cold - Heat Instructions to relieve pain and swelling, and promote healing.
•	Protect Your Back When Lifting by using these five simple steps.

Call or contact us if you have any questions about filling out these forms.

Click here for a map to our office.

We look forward to seeing you soon.

Pearson Chiropractic & Rehabilitation Center
Dr. Jay Pearson
Address: 13003 SE Kent Kangley Rd. Suite 110
Kent, WA 98030
Phone: 253-638-2424
Email: info@pearsonchiropractic.com

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