If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

Gerckens Chiropractic & Wellness Center offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have Adobe Reader® 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 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!

Forms for ALL new patients:


If involved in a car accident:


If you choose to check one or both of the boxes in the Acknowledgement of Receipt of Notice, the forms associated with them are:


For patients under 18 years of age:



Download the Free Adobe Reader®

Exclusive Offer

New patients receive $15 OFF of nutritional and herbal supplementation.

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

Office Hours

DayMorningAfternoon
Monday7:30 - 12:002:00 - 6:00pm
TuesdayClosed2:00 - 6:00pm
Wednesday7:30 - 12:002:00 - 6:00pm
Thursday8:00 - 12:002:00 - 6:00pm
Friday7:30 - 12:002:00 - 6:00pm
Saturday8:15 - 10:30Closed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:30 - 12:00 Closed 7:30 - 12:00 8:00 - 12:00 7:30 - 12:00 8:15 - 10:30 Closed
2:00 - 6:00pm 2:00 - 6:00pm 2:00 - 6:00pm 2:00 - 6:00pm 2:00 - 6:00pm Closed Closed

Testimonial

Dr. Gerckens is the best chiropractor I have been to. I severely pinched my sciatic nerve 25 years ago. I walked with tremendous pain until I saw a chiropractor.The chiropractor I saw provided some relief, but the problems kept returning. I visited many chiropractors over the years, but my back pain did not permanently end until I visited Dr. Gerckens.

T.B
Ventura, CA

Newsletter Sign Up