Patient Forms

Upon entering our office our receptionist will greet you and welcome you as a member of our family.  We will request you fill our patient forms, click here to download and print our patient forms ahead of time. The paperwork provides us with general information about yourself and your condition.


Next, you will have a consultation with the doctor to discuss your health-related problems, concerns, as well as potential treatment options. Your first visit is designed for the doctor to learn more about you, your condition and your expectations to determine whether our care will you meet your goals.


After your consultation, your doctor will perform a  chiropractic examination testing your reflexes, your ability to turn and bend as well as other standard neurologic, orthopedic, postural, and physical examinations.  We will also check for the six interferences to health. Nothing will be done in our office without your consent. Generally, no treatment is given on the first visit.  Occasionally the Dr. may deem it necessary to initiate some treatment on this visit.

Report of Findings

Once all the information and examinations have been performed, the doctor will give you a report of findings to answer the three most popular questions:

  1. Can you help me?
  2. What do you recommend that I do to get better?
  3. How much is it going to cost?

After discussing with you your history and your goals, examining your spine and reviewing any tests such as blood tests that you have brought in with you, the doctor will discuss recommendations with you. If you have a condition that requires care with other providers, the doctor will tell you. If the doctor believes we can help you, we will recommend treatment and a wellness program.


Patients will generally be provided with their first treatment at the conclusion of the appointment. This may include spinal adjustments, foot baths, soft tissue release, homeopathy and/or nutritional recommendations.

Wellness Program

Prior to leaving, patients will be instructed on a wellness program to be conducted at home. Everybody is unique and different and therefore everyone requires a unique and customized wellness plan.  The foundation of our overall wellness lifestyle is maintaining a healthy posture and good spinal alignment, eating a healthy diet, taking supplements, keeping your weight under control and stress relief.


Many people  come to us because they are in some kind of discomfort or pain. In this first phase of care, the main goal is to reduce your symptoms. Most people are under the assumption that if they don’t feel any pain that there is nothing wrong with them – that they are healthy. Unfortunately, pain is a very poor indicator of health. In fact, pain and other symptoms frequently only appear after a disease or other condition has become advanced.

For example, consider a cavity in your tooth. Does it hurt when it first develops or only after it has become serious? How about heart disease? Regardless of whether you are talking about cancer, heart disease, diabetes, stress or problems with the spine, pain is usually the last thing to appear. When you begin  care, pain may be the first symptom to disappear, even though much of the underlying condition remains.


Most chiropractors regard the elimination of symptoms as the easiest part of a persons care. If all that the chiropractor does is to reduce the pain and stop there, the chances of the condition recurring are much greater. In order to prevent a rapid recurrence of symptoms, it is necessary to continue receiving care even though your symptoms are gone.

Do not be discouraged if you have mild flare-ups in your symptoms on occasion. This is normal. Flare-ups are bound to occur during this phase because your body has not fully healed. Depending on the severity of your injury or condition and how long you have been suffering from it, this phase of your care may last anywhere from a few months to a couple of years.


Once your body has fully healed, routine check-ups can help ensure that your physical problems do not return, and keep your body in optimal condition. Just like continuing an exercise program and eating well in order to sustain the benefits of exercise and proper diet, it is necessary to continue care to ensure the health of your system. When you make routine care a part of your lifestyle, you avoid many of the aches and pains that so many people suffer through,  and you will be able to engage in more of the activities you love.


We are dedicated to the wellness care of all our clients and not to health care that is dictated to us by the insurance companies. Because of this we do not accept insurance or give a receipt for insurance reimbursement.

If your flex plan accepts a copy of your credit card receipt or a copy of your check you can submit them to your flex plan. However, if your flex plan needs any type of verification of treatment we do not offer that to our clients.

We do not accept Medicare. We do treat patients that are over the age of 65 but we do not do Chiropractic Adjustment on those over the age of 65.

We do expect payment as services are rendered.  We accept Master Card, Visa, Discover, Cash or check for services received. (We do not accept post-dated checks.)


Holze Wellness Center offers our patient forms online so you can complete it in the convenience of your own home or office.

  1. If you do not already have AdobeReader® installed on your computer, click the Adobe® image to download it for free.
  2. Click on the necessary form, print it out and fill in the required information.
  3. Fax us your printed and completed forms or bring them with you to your appointment and save time on your visit!


Download the Free AdobeReader®

New Patient Health History Forms


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

pdf Crisis Exam Form

pdf Comprehensive Exam Forms