Laurie Kelleher, D.C. offers our patient form(s) online so they can be completed 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.

Patient Forms

The links below will provide you with our patient forms. Please print these out and complete them. Then, bring the completed forms with you when you come for your first visit.

All patients please download and complete the following:

1. Patient Intake Form / Medical History
   
2. Notice of Privacy Practices (with acknowledgment)
3. Authorization to Release Records
4. Cancellation Policy
   

Motor vehicle accident patients, in addition to the forms listed at the top of this page, please download and complete the following:

• Vehicle Accident Information Intake Form
  
• New York No Fault Insurance Law Assignment of Benefits Form

Workers' Comp patients, in addition to the forms listed at the top of this page, pelase download and complete the following:

• Workers Compensation Questionnaire
  

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!