University Chiropractic

2717 Western Bypass #109, Durham, NC 27705

(919) 493-1940 / Request An Appointment Today!

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Online Forms

patient forms Durham, NC

CHIROPRACTIC FORMS

 CHIROPRACTIC PATIENT INTAKE FORM – Click to Complete
 CHIROPRACTIC PEDIATRIC INTAKE FORMS – Click to Complete

PERSONAL INJURY AND MEDICARE FORMS

 CHIROPRACTIC PERSONAL / AUTO INJURY INTAKE FORM – Click to Complete
 NECK DISABILITY INDEX QUESTIONNAIRE – Click to Complete
 OSWESTRY LOW BACK PAIN INDEX QUESTIONNAIRE – Click to Complete

MASSAGE FORMS

 MASSAGE PAPERWORK – Click to Complete

PERSONAL HEALTH FORMS

 REQUEST TO RELEASE MEDICAL RECORDS – Click to Complete
 NOTICE OF PRIVACY ACTS – Click to View
 PHI DISCLOSURE – Click to Complete
 REQUEST TO ACCESS & REVIEW PHI – Click to Complete
 REQUEST FOR AMENDMENT OF PHI – Click to Complete

SPANISH FORMS

 QUIROPRÁCTICA: FORMULARIO DE ADMISIÓN DEL PACIENTE
 QUIROPRÁCTICA: FORMULARIO DE ADMISIÓN PARA NIÑOS
 QUIROPRÁCTICA: FORMULARIO DE ADMISIÓN POR LESIONES PERSONALES / AUTOMOVILÍSTICAS
 AVISO DE PRÁCTICAS PRIVADAS

Get In Touch With Us Today

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  • Please use this form for general information purposes only. DO NOT send personal health information through this form. Specific patient care must be addressed during your appointment.

Office Hours

Monday: 7:30am – 12:30pm | 2:00pm – 6:00pm
Tuesday: 2:00pm – 6:00pm
Wednesday: 7:30am – 12:30pm | 2:00pm – 6:00pm
Thursday: 7:30am – 12:30pm | 2:00pm – 6:00pm
Friday: 8:00am – 1:00pm
Saturday: Closed

Appointments

We will do our best to accommodate your busy schedule. Request an appointment today!

Request Appointment

Get In Touch

(919) 493-1940

2717 Western Bypass #109,
Durham, NC 27705

University Chiropractic

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