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!
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
- New Patient Information
- Health History
- PPO Financial Policy
- Monarch IPA Financial Policy
- Managed Care Policy
- Cash Financial Policy
- Out-of-Network Financial Policy
- Medicare Financial Policy
- Medicare Non-coverage ABN Form
- PI/Auto Accident Financial Policy
- Auto Accident History Form
- Auto Accident Symptom Survey
- Pain Scale-VAS
- Non-Covered Additional PT Services
- Pain chart
- Neck questionnaire
- Low back questionnaire
- Upper extremity questionnaire
- Lower extremity questionnaire
- Auto Insurance Verification
- What to Expect after a Chiropractic Adjustment
- Functional Nutritional-Wellness Financial Policy
- Functional Nutritional-Wellness Liability Waiver
- Functional Nutritional-Wellness Health History