Online Forms

Burtonsville Chiropractic & Rehab offers our patient forms online so you can complete 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 forms, print it out and fill in the required information.
• For New Patients, please be sure to print out the New Patient Health History Form and the New Patient Chemical Balance Questionnaire.
• Once you have printed and completed the forms, bring them with you to your appointment.

New Patient Forms

New Patient Health History Form - Required

This let’s 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

New Patient Chemical Balance Questionnaire - Required

This is Part II of our Health History Form.  Please print out, fill out and present before your initial visit.

Download and 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!

Download & Print Form

 Existing Patient Forms

Daily Diet Log - Required

After your intial visit, this form should be filled out completely for seven consecutive days and presented to Dr. Lea for review.

Download & Print Form

Urine pH Testing Instructions

After your intial visit, evaluation of your urine pH will done.  Please print out form and follow the instructions therein.

Download & Print Form