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Democko Chiropractic offers our patient form(s) online so they can be completed 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.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.


New Patient Information Welcome Sheet -Required

This sheet gives us your personal information needed to input into our system such as name, address, contact information and insurance information. 

New Patient Health History Form - Required

This lets us know the history and current state of your health. This is a two sided form for both sides. Please make sure that you complete both sides and sign at the bottom.What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Patient Consent Form - Required

This informs you that your records are confidential and we are NOT allowed to release them to anyone without your permission.

Download and Print Forms

ALSO, IF YOU ARE CURRENTLY TAKING ANY MEDICATIONS (PRESCRIPTION AND/OR OVER THE COUNTER) PLEASE BRING A LIST OF THOSE.

Please do not date any of these forms. We will do that when you come in for your appointment. There will be some additional paperwork depending upon what type of patient you are.


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



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Military Discount

 

1st Visit Only $40 and Adjustments After That Are Just $25.

Sign-up using the form or call us at 919-735-2205 to take advantage of this exclusive offer.

THIS ---->https://goldsborochirocom.chiromatrixbase.com/new-patient-center/online-forms.html

Office Hours

DayMorningAfternoon
Monday8:00am - 12:00pm2:30pm - 6:00pm
Tuesday9:00am - 12:00pm2:30pm - 5:00pm
Wednesday8:00am - 12:00pm2:30pm - 6:00pm
Thursday8:00am - 12:00pm2:30pm - 6:00pm
Friday8:00am - 12:00pmClosed
SaturdayBy AppointmentClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00am - 12:00pm 9:00am - 12:00pm 8:00am - 12:00pm 8:00am - 12:00pm 8:00am - 12:00pm By Appointment Closed
2:30pm - 6:00pm 2:30pm - 5:00pm 2:30pm - 6:00pm 2:30pm - 6:00pm Closed Closed Closed

Testimonials

After my visits to his office, I had more mobility and less pain. I was not able to move around without worrying of falling before I started with care here. I would tell anyone that needs some relief to go get some help-Don't try to live with the pain.

D. Youngs

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