Online Forms

Steven B. Wasserman, R. N., D. C. offers our patient form(s) 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 form(s), print it out and fill in the required information.
  • Bring your printed and completed form(s) to your appointment or Fax them to (562) 430-7544.

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!

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Forms to Download and Print   

*Please bring in the forms filled out on your first visit or fax them before your first appt. to 562.430.7544


1.  In Network Forms

New Patient Information
Health History
PPO Financial Policy


2.  Out-of-Network Forms

New Patient Information
Health History
Out-of-Network Financial Policy 


3.  Medicare Forms

New Patient Information

6.  PI Forms
New Patient Information
Health History
PI/Auto Accident Financial Policy
Auto Accident History Form Auto
Accident Symptom Survey
Pain Scale-VAS
Pain chart
Neck questionnaire
Low back questionnaire


7.  WC Forms

New Patient Information
Health History
Pain Scale-VAS
Pain chart
Neck questionnaire
Low back questionnaire
Upper extremity questionnaire
Lower extremity questionnaire

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  1. New Patient Information
  2. Health History
  3. PPO Financial Policy
  4. Monarch IPA Financial Policy
  5. Managed Care Policy
  6. Cash Financial Policy
  7. Out-of-Network Financial Policy
  8. Medicare Financial Policy
  9. Medicare Non-coverage ABN Form
10. PI/Auto Accident Financial Policy
  1. Auto Accident History Form
  2. Auto Accident Symptom Survey
  3. Pain Scale-VAS
  1. Pain chart
  2. Neck questionnaire
  3. Low back questionnaire
  4. Upper extremity questionnaire
  5. Lower extremity questionnaire
  6. What to Expect after a Chiropractic Adjustment













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Locations

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Office Hours

Los Alamitos Office

Monday:

8:00 am-12:15 pm

2:30 pm-6:00 pm

Tuesday:

2:30 pm-6:00 pm

Wednesday:

8:00 am-12:15 pm

2:30 pm-6:00 pm

Thursday:

Closed

Friday:

8:00 am-12:15 pm

2:30 pm-5:00 pm

Saturday:

Closed

Sunday:

Closed

Testimonials

  • "Where Experience and Compassion for Your Health
    Make a Difference."