New Patient Paperwork

We are happy to offer our intake forms online for your convenience. Please feel free to complete these forms in your home prior to your appointment so that we can be prepared for your visit. We look forward to meeting you! Please give us a call at (408) 246-1738 if you have any questions.

Please complete this form if you are over the age of 18.

Please complete this form if you are bringing in a child 17 or under.

Please complete this form if you are coming to see us as a result of an injury or accident.

Please complete this form for a wellness evaluation.

OFFICE HOURS


Monday
10:00am - 1:00pm
3:00pm - 6:00pm


Tuesday
1:00pm - 7:00pm


Wednesday
10:00am - 1:00pm
3:00pm - 6:00pm


Thursday
1:00pm - 7:00pm


Friday
8:00am - 1:00pm


Saturday
Closed

Element Chiropractic Wellness
68 Harold Avenue #101
Santa Clara, CA 95050
(408) 246-1738