Online Forms

Rutherford Clinic of Chiropractic 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 Health History Form - Required

All cash, major medical and medicare patients must complete the questionnaire both sides front and back.

Workman's Compensation Forms

Workman's compensation must complete all forms

Patient History Form

Download & Print Form

Compensation Authorization Form

Download & Print Form

Compensation Questionnaire Form

Download & Print Form

Personal Injury Forms
Personal Injury patients must complete all forms and state if the injury is due to a motor vehicle or non motor vehicle incident.

Patient History Form

Download & Print Form

Personal Injury Verification Form

Download & Print Form

Personal Injury Questionnaire Form

Download & Print Form

Patient Records and Doctor's Lien Form

Download & Print Form

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!