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FORMS

Dr. Maria's office offers the patient forms online so they can be completed in the convenience of your own home or office. If for some reason, you are not able to complete the forms online, notify the office. In this case, you will need to arrive 15-30 minutes early for your appointment in order to fill them out.

The Patient Health History Form must be completed by all patients, except children (ages 12 and under).

The above link will allow you to submit your information electronically to our office, make sure to click the SUBMIT button at the bottom of the page.

If you would rather Print the Patient History Form to fill out and bring into the office, please use this link. (use above link if you intend to fill the form out online to submit directly)

Fill this Metabolic Assessment Form out if you feel you are not 100% well! This is a basic assessment of organ and/or endocrine function. It helps the doctors determine where to begin your healing.

Be sure to check out the contact page to see where we are located.

If you would like to use your health insurance, please view the Insurance Verification Form. You will need to call your insurance company and ask each question on your form. If you find it is to your benefit to utilize insurance, we will provide you with the necessary superbill. 

Brain Health and Nutrition Assessment Form (form may take a moment to load)

Fill this form out if you experience depression, anxiety, insomnia, memory loss or just want to know how to improve/preserve your brain health. This is useful to prevent brain degeneration and/or improve emotional well being.

Please print and bring this form with you to the office.

Brain Function Assessment Form

This form helps the doctor determine which areas of the brain may be malfunctioning.

Fill this form out if:

  • you have ever suffered a concussion
  • you have anxiety or depression
  • you feel your brain does not function as well as it used to
  • you have neurological problems
  • you want to slow down aging of your brain

Print and bring form with you to your appointment

Brain Region Assessment

This form helps determine what areas of the brain are starting to degenerate or have been impacted by insults such as concussion or toxin

Fill this form out if:

  • you have had a brain insult
  • you are concerned about memory loss and/or age related effects on the brain
  • you are concerned about overall brain health

NeuroToxic Questionaire

Many of us have been exposed to chemicals that can accumulate and cause health problems. This form will help the doctor determine if biotoxins may be affecting you.

Biotoxins include mold, lyme, chronic viruses (herpes, epstein barr) and chemicals

If you have odd or unexplained symptoms this may be the answer.


Pediatric Health History Form is required for infants and children under 12.

Many things can occur early in life that cause maladaptions of the nervous system.


Employment Application

If you are good with technology, love people, have a thirst to learn and are organized, let's talk! We are a busy Holistic/chiropractic clinic. Job duties include assisting doctor, scheduling and coordinating patients, marketing and managing email/Social media. Pay dependent on skills and experience, we are willing to train the right person. Flexible hours.

Please print or email the application to the office. Please include resume. 

Our office helps individuals and families obtain optimal health and wellness through neurologically based Chiropractic Care and Functional Medicine. We provide the most advanced Chiropractic & Holistic care by focusing on research, ongoing training, and the implementing of the latest advancements in technology. We empower our patients to take charge of their health by being proactive with a natural approach rather than reactive. It is our mission to create a community in which individuals first look to the body to make health decisions, rather than the medicine cabinet. We take pride in helping our patients build the foundation to a healthy and pharma free life. 


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