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37 1/2 Forrester Street Newburyport, MA 01950
978-463-8881
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Active Life Chiropractic offers our patient form(s) online so they can be completed it in the convenience of your own home or office.

  • If you do not already have AdobeReader® 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.

Please note that due to the potential longer time of your first visit a $25 charge will required to be payed by the patient if a new patient appointment is cancelled without 24 hours notice

NP Health History and Insurance Authorization - 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!

Complete Online and Submit (Prior to your first visit)


Outcome Assesment Forms : Please choose back or neck or both, depending on your location of discomfort.

Bournemouth Neck

Download & Print Form

Bournemouth Back

Download & Print Form

Functional Rating Index

Download & Print Form



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