Relief Is Ahead

Patient Forms
Schedule An AppointmentContact Us
Welcome!

Download your forms here, and speed up the process.

Stoetzel Chiropractic Clinic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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.
Frequently Asked Questions
How Long Does the Process Take?
Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.
Does Insurance Cover All Treatments?

Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.

Is the therapy painful?

Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.

How long is each appointment?

Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.

Will be able to drive myself home?

Ut enim ad minim veniam, quis nostrud exercitation ullamco laboris nisi ut aliquip ex ea commodo consequat. Duis aute irure dolor in reprehenderit in voluptate velit esse cillum dolore eu fugiat nulla pariatur.

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? Please print out all the forms associated with your case and have them filled out by your first appointment. If you are unable to print out the forms ahead of time, please arrive to the clinic up to 30 minutes before your scheduled appointment to fill out the paperwork.

New Patient Intake forms (Cash or Insurance Patients)
Informed Consent Form
New Patient Intake Form
Signature On File Form
Pain Diagram (English)

New Personal Injury Intake forms (Motor Vehicle Accident Patients)

New Patient Personal Injury Intake Form
New Patient Personal Injury Intake Part 2 Form
Assignment of Benefits Form
Informed Consent Form
Pain Diagram (English)

Questionnaires

Headache
Neck
Back
Lower Back
Roland-Morris
Back Bournemouth

Quick Links

Neck Pain

Herniated Discs

Auto/Work Injury

Upcoming Events

Health Fair

Sept 24, 11am

Free Evaluations

Sept 28, 11am

Health & Nutrition

Sept 30, 1pm

Get In Touch

(336) 773-1177
Email Us

Visit Us

3333 Brookview Hills Blvd
Suite 101
Winston Salem, NC 27103

Back Pain Relief

Get relief from constant or very painful back pain today. Schedule an appointment.

Our Staff

Learn more about our staff here at Stoetzel Chiropractic in Winston-Salem NC.

en_USEnglish