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716.648.7613 H
H

716.648.7613

Online Forms

Safe Harbor Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive at our office.

  • If you do not already have AdobeReader® installed on your computer, click here to download the latest version.
  • Download the necessary form(s), print and complete.
  • Simply bring your completed forms with you to your first appointment. Alternately, you can scan and email them to us at scheduling@safeharborchiropractic.com or fax your completed forms to (716) 648.7631 

New Patient Health History Form - Required

The information gathered within these forms lets us know your health history as well as your current health status. Patient intake is accessed online and will be sent securely to our software upon completion. Please print and complete all other forms and bring them along to your initial evaluation. What wellness-related questions, concerns, and goals can we help you with? Let us know! Please note that patients aged 15 and under must have our Pediatric Case History & Intake completed on their behalf.  Click the link above to complete our online intake forms. Please note this form is not mobile-friendly. 

Patient Intake Online Form Click this to complete our online intake forms. Please note this form is not mobile-friendly.

Please note that patients aged 15 and under must have our Pediatric Case History & Intake completed on their behalf.  

Fee Schedule Download & Print Form

Patient Authorization Download & Print Form

Privacy Policy Download & Print Form

Terms of Acceptance & Office Policy Download & Print Form

Pediatric Case History & Intake (for patients aged 15 and under)  Download & Print Form


Progress Exam Forms

Progress Update Download & Print Form


No-Fault Accident Case Forms 

Patient Intake - Access Form Online

Neck and Back Index Download & Print Form

Fee Schedule Download & Print Form

Patient Authorization Download & Print Form

Privacy Policy Download & Print Form

Terms of Acceptance & Office Policy Download & Print Form


No-Fault Accident Progress Exam Forms 

Neck and Back Index Download & Print Form


Nutritional Therapy Forms 

If you are scheduled for either a Nutrition Response Technique appointment or Heart Sound Recorder appointment, please download and complete these forms prior to it. Kindly note that the Nutrition Response Therapy Complete Packet requires several days of food logging, so the earlier you can look at these before you appointment, the better. Disregard and do not complete Barnes' Thyroid Test on page 3. 

For an initial Heart Sound Recorder appointment, please review Heart Sound Recorder Initial Preparation Instructions and follow them as closely as possible. 

Heart Sound Recorder Initial Preparation Instructions - Download & Print Forms

Nutritional Response Therapy Complete Packet - Download & Print Forms

Response Heart Sound Recorder Consent Form - Download & Print Form

Testimonial

Provide us with a testimonial of your KST experience and receive a free 15-minute HydroMassage!

Office Hours

DayMorningAfternoon
Monday10:30 - 12:002:30 - 5:30
Tuesday9 - 122:30 - 5:30
WednesdayClosed4 - 7
Thursday9 - 12:002:00 - 4:30
FridayClosedClosed
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
10:30 - 12:00 9 - 12 Closed 9 - 12:00 Closed Closed Closed
2:30 - 5:30 2:30 - 5:30 4 - 7 2:00 - 4:30 Closed Closed Closed