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Lipkin Chiropractic Clinic of Palm Harbor offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Print the necessary form(s), Complete and DATE for the Date of your appointment.
  • Bring your printed and completed form(s) to your appointment.

INITIAL VISIT Health History Form

For a New Patient (or existing patients last seen over 3 years from last visit)  

Print New Patient / Initial Visit Form 


RE-EXAMINATION - Follow-up Questionnaire (for re-exams to check progress)

Print Re-Exam Form


NECK  INDEX

Print Neck Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your NECK condition affects this activity.  

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of NECK pain.


BACK  INDEX

Print Back Index Form

Part 1 - Choose ONE statement from each activity that BEST describes how your BACK condition affects this activity.

Part 2 - Place a mark on the bottom line to indicate the INTENSITY of BACK pain.


ACUPUNCTURE - Intake Form

Print Acupuncture Form


PRE-PARTICIPATION SCHOOL PHYSICALS  

$20 all day, everyday

Print School Physical  (EL2) Form

Please fill out Page 1 and the top of Page 2 prior to examination

Pinellas County Middle School and High School Athletic Programs

FHSAA Pre-participation Physical Evaluation Form EL2 (rev.5/14)

 V70.3 ICD-9-CM


Member Wellness Registration Form

You can also sign up for our monthly newsletter; and, for access to our member wellness section of our website.  Keep up on current health issues and news.

You can  Click Here to register online!

We look forward to making your experience with our office and website more interactive and rewarding!


Download the Free AdobeReader®

THIS ---->https://lipkinchiropracticcom.chiromatrixbase.com/print-forms.html

Office Hours

DayMorningAfternoon
Monday8:30 - 12:002:45 - 6:00
TuesdayCall for Appt2:45 - 6:00
Wednesday8:30 - 12:002:45 - 6:00
ThursdayBy AppointmentBy Appointment
Friday8:30 - 12:002:45 - 6:00
SaturdayBy AppointmentClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30 - 12:00 Call for Appt 8:30 - 12:00 By Appointment 8:30 - 12:00 By Appointment Closed
2:45 - 6:00 2:45 - 6:00 2:45 - 6:00 By Appointment 2:45 - 6:00 Closed Closed

(727) 787-4787

New Patient
Website SPECIAL

$145
all inclusive
One DAY

To assist those without adequate insurance.
This Website Offer Includes:

History Consultation ;
Examination ;
Findings Consultation
(with recommendations for care);
Spinal Treatment
and Therapy

SERVICES IF MEDICALLY NECESSARY. THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR BE REIMBURSED FOR PAYMENT FOR ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF AND WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR THE FREE, DISCOUNTED OR REDUCED FEE SERVICES, EXAMINATION OR TREATMENT.CPT (total value over $300); Codes 99201-99204, 98940-2; G0283, 97530, 97110, 97010)

3D Spine Simulator



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