New patient forms are available for download below. Please complete the forms before arriving at our office for your appointment.

IMPORTANT INFORMATION:
Please fill out and sign all forms below. You may fax them to our office or      bring them with your to your appointment. Thank you.


New Patient Health History Form and 3 Day Food Log - Required
The Patient Health History and Food Log lets us understand your history and current state of health. What questions, concerns, goals, etc. regarding wellness can we help you with? Let us know!

Download & Print - New Patient Health History Form / Food Log



Notice of Privacy Practices - Required
A summary disclosing how health information about you may be used. Please read, sign and bring to your appointment with you.

Download & Print - Privacy Practices Summary



​​Office Policy - Required
Guidelines for patients about procedures, payment expectations, appointment cancellations & what we expect from you. Please read, sign and bring to your appointment with you.

Download & Print - Office Policy



~If you do not have AdobeReader, click here to download​: Download the Free AdobeReader®

Mitchell Peritz D.C. believes in the value of chiropractic care for you and your family, working toward the goal of achieving total health and wellness.

Appointment fees are based on hourly rates: $165.00 per hour, $85.00 per half hour
Payment in full is expected at the time of service. We accept only check or cash payments. Patients with insurance coverage for the services rendered, will be given the appropriate, completed insurance forms to submit for reimbursement.

A 48-Hour Cancellation Policy is in effect. If an appointment is missed within 48 hours of the appointment time, you will be responsible for payment in full.
Patient Forms
Copyright © 2014 - Dr. Mitch Peritz ® - All Rights Reserved | Contact Us | New Patient Forms | Blog
Webdesign by: lionspengraphics.com

Office Hours:

Services Are Provided 
by Appointment Only.

Please call (303) 541-9019 or email us today to make an appointment.
Office Policy