Patient Forms

Please click on the links below to view and print our new patient forms. If you are having trouble viewing these forms, you may need to install Adobe Reader. Click here to install Adobe Reader.

Patient Information Form

The Patient Information Form is for all our new clients. It provides us with all your basic information such as your name, emergency contact, and your desired payment method.

Medical and Health History Form

The Medical & Health History form is for our team to learn as much about you as possible; therefore, we can provide you with the correct care. This form is important in helping us get you towards living a happier and healthier life.

Assignement of insurance form

The Assignment of Insurance form is the legal document that will give your insurance company permission to pay the bill by check and mail it to Harchak Chiropractic. The reason why we need this filled out is so we can make the payment process as easy and efficient as possible with your insurance company.

Contact Us

We look forward to hearing from you.

Our Location

1114 Walton St. | Phillipsburg, PA 16866

Office Hours

Find Out When We Are Open


8:00 am-7:00 pm


9:00 am-2:30 pm


8:00 am-7:00 pm


2:00 pm-7:00 pm


7:30 am-12:00 pm