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New patients receive 20% OFF first visit with this coupon!

Sign-up using the form or call us at 337-534-0094 to take advantage of this exclusive offer.

Online Forms

Daly 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 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.

New Patient Health History Forms - 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!

New Patient Intake Form - Click Here
HIPAA Patient Consent Form - Download &  Print Form
Informed Consent to Chiropractic Treatment - Download & Print Form
Policy on Insurance Assignment - Download & Print Form


Download the Free AdobeReader®