Online Forms

Prax Chiropractic and Holistic Pediatrics offers our patient form(s) online so you can complete them in the convenience of your own home or office. In our effort to "Go Green" by going paperless, we now have our New Patient Intake Form online. 

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Please download the "required" forms below, print them out and fill in all the required information.  Please be as detailed as possible.  If something doesn't apply, please print "N/A" on that line. 
• If you should have any questions, feel free to call us at 434-977-5433.
• Please fax us your printed and completed forms or bring it with you to your appointment. 
• Fax (434) 977-1360

New Patient Health History Form - Required

Fill out either this form...

New Patient Intake Form - This form is an online PAPERLESS form.  Just click on the hyperlink and fill it out online.  Make sure to "submit" it.

or this form. One or the other.

Download & Print Form  - If you prefer to do it "The Old Fashioned Way", click on this link, print out the form, fill it out and bring it in with you to your appointment. It wastes paper and takes longer though.

Pediatric New Patient Health History Form - Required (ONLY to be used if the patient is 10 years old or YOUNGER)

Download & Print Form

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Terms of Acceptance Form and HIPPA Privacy Form - Required

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!