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Request An Appointment

216-231-5783

Cleveland Chiropractic and Wellness 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 Health History Form - Required

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!

Download & Print Form


Nutrition and Wellness Intake Form

Download & Print Form


Standard Process Symptom Survey

The Standard Process Symptom Survey is designed to let us know what symptoms you have and which supplements we need to recommend to get you back on the track to wellness.

(all 4 pages must be completed)

/clients/3837/documents/Standard_Process_Page_1.pdf

/clients/3837/documents/Standard_Process_Page_2.pdf

/clients/3837/documents/Standard_Process_Page_3.pdf

/clients/3837/documents/Standard_Process_Page_4.pdf


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