MillerVillage Chiropractic Center 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) to 225-291-2628 or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Also, please sign up for our monthly newsletter (see newsletter button at the upper-right side of  banner)  to keep up on current health issues and news and events in our office.

UnitedHealthCare

If UnitedHealthCare is your insurance company, please complete the following required forms in addition to the new patient form: 

For a neck complaint, complete the Patient Summary and the Neck Index

For a back complaint, complete the Patient Summary, Back Index and Lower Extremity Functional Scale

For an Arm, Shoulder and Hand complaint, complete the Patient Summary and DASH

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!