Prairielands Chiropractic Clinic 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.
• Fax us your printed and completed form(s) to (712) 256-1927 or bring it with you to your appointment.
• Complete and submit online.
  

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 what your health goals are!

Click to Download & Print pdf Form
Click to Complete & Submit Online Form

Personal Injury Cases - Car Accidents or Slip and Fall Injuries Only
If you have been involved in an AUTO ACCIDENT or suffered a personal injury then please fill out the following form.

Click to Download & Print pdf Form    (coming soon.)

Pediatric Health History Form - Required for ages birth - 12 years

Click to Download & Print pdf Form
Click to Complete & Submit Online Form

Massage Consent Form - Required before 1st. massage

Click to Download & Print Form
Click to Complete & Submit Online Form

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!

Click to Download & Print pdf Form