These forms may be downloaded and printed; you may bring completed forms with you to your visit, or mail them (in advance) to our office:
Chiropractic Neurology Center
9302 N. Meridian St., Suite 170
Indianapolis, IN 46280
Please do NOT email them since they contain confidential (protected) medical information.
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Form Name
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Adobe PDF
Reader (*.pdf format)
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Microsoft
Word (*.doc format) |
| Accident Injury Report | ||
| Autism Treatment Evaluation Checklist | ||
| Back Pain Report Form | ||
| Credit Card Guarantee Form | ||
| Consent for Treatment | ||
| Financial Policy | ||
| Health Questionnaires (3 parts): | ||
| 1. Neurotransmitter Assessment Form (NTAF) - includes Medication History Form |
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| 2. Metabolic Assessment Form | ||
| 3. Health Refocus Questionnaire | ||
| Neck Pain Report Form | ||
| “New Patient” Health History Form | ||
| Notice of Patient Privacy Policies | ||
| Record Transfer Release | ||
| “Signature on File” Permission Form | ||
| X-Ray Payment Assignment Form | ||
| Note: PDF files require Adobe Acrobat Reader™ to view. To download a free copy of Acrobat Reader in a new window – Click Here | ||
For more information about Chiropractic Neurology Center and the conditions we treat, or to schedule an appointment for consultation, contact us.
We treat, without prescription medication, the underlying causes of physical pain, difficulty moving, attention deficit, depression and many other debilitating or painful chronic conditions.
Learn how the nationally-recognized Brain Balance Achievement Center in Indianapolis helps children ages 6-13 overcome ADD / ADHD and other learning and behavioral challenges.