Lake Shore Chiropractic Center
  • Home
  • About Our Practice
    • Our History
    • Our Professional Chiropractic Team
    • Our Amazing Chiropractic Support Team
    • Organizations We Support
  • Patient Center
    • Conditions Treated
    • What to Expect on Your First Visit
    • Patient Forms >
      • New Patient
      • Established Patient
    • Insurances Accepted
    • Payment and Fees
    • Office Hours and locations
    • Products
  • Services
    • Chiropractic Manual Manipulation
    • Active Release ART
    • Cox's Distraction
    • McKenzie Methods
    • Graston/IASTM Techniques
  • Contact Us
    • Office Locations and Hours
  • Pain Relief Products
    • CBD Analgesics
    • Biofreeze
716-646-4000

New Patient Forms

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New Patient Intake Forms

​Please fill out the form below as it will save you time when arriving to our office and will allow the doctor to review your case prior to seeing you. Welcome to our office!
 
Adult New Patient Intake Form:
New Patient Intake Form
File Size: 233 kb
File Type: pdf
Download File

Minor (under 18 years old)- Parental Release
Minor Consent Form
File Size: 169 kb
File Type: pdf
Download File


Palladium Forms for Univera Patients​
Adult Form: 
If you have Univera insurance, in addition to the form above, please fill out this form below so we may process your insurance properly.
Palladian Chief Complaint Form
File Size: 24 kb
File Type: pdf
Download File

Pediatric Form:
​​Please fill out the form below so we may process your insurance properly.
​(5th section form the top of the page)
Minor Consent Form
File Size: 167 kb
File Type: pdf
Download File


Functional Questionnaires

​Low Back Index - Oswestry
Oswestry Back Questionairre
File Size: 24 kb
File Type: pdf
Download File


​Neck Disabillity Index
Neck Disability Index Questionairre
File Size: 24 kb
File Type: pdf
Download File


Additional Forms

Motor Vehicle Accident Intake Form
Motor Vehicle Accident Intake Form
File Size: 594 kb
File Type: pdf
Download File


Workers' Compensation/Work Injury Forms​
Workers' Compensation Questionnaire
File Size: 99 kb
File Type: pdf
Download File


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  • Home
  • About Our Practice
    • Our History
    • Our Professional Chiropractic Team
    • Our Amazing Chiropractic Support Team
    • Organizations We Support
  • Patient Center
    • Conditions Treated
    • What to Expect on Your First Visit
    • Patient Forms >
      • New Patient
      • Established Patient
    • Insurances Accepted
    • Payment and Fees
    • Office Hours and locations
    • Products
  • Services
    • Chiropractic Manual Manipulation
    • Active Release ART
    • Cox's Distraction
    • McKenzie Methods
    • Graston/IASTM Techniques
  • Contact Us
    • Office Locations and Hours
  • Pain Relief Products
    • CBD Analgesics
    • Biofreeze