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Smith Upper Cervical Chiropractic 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) or bring it with you to your appointment.

New 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!

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If you were involved in an Accident use this form

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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!

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THIS ---->https://rogerdsmithdc.chiromatrixbase.com/online-forms.html

Office Hours

Day
Monday9:00 - 1:003:00 - 6:00
Tuesday9:00 - 1:003:00 - 4:00
WednesdayClosedClosed
Thursday9:00 - 1:003:00 - 6:00
Friday9:00 - 1:003:00 - 4:00
Saturday9:00 - 11:00Closed
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00 - 1:00 9:00 - 1:00 Closed 9:00 - 1:00 9:00 - 1:00 9:00 - 11:00 Closed
3:00 - 6:00 3:00 - 4:00 Closed 3:00 - 6:00 3:00 - 4:00 Closed Closed

Testimonials

My pain is gone! I had resolved myself that this nagging, chronic pain in my neck and shoulders was simply "part of life". Thanks to Dr. Smith's precision Upper Cervical adjustments I am pain free! Many thanks to your mindful approach to the health and well being of your patients.

Jo Dawson
Huntington Beach, CA

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