Richard C. Gerardo

D.C., C.S.C.P., D.A.C.B.N.

Chiropractic - TMJ Therapy

Burbank

(818) 567-0866

Thousand Oaks

(805) 409-3160

Here are all the forms you will need before your appointment. You can print these and fill them out before your visit. Thank you!

 

patient-forms-dr-gerardoAll Patient Forms in One Packet

View in Adobe Acrobat

View in Google Docs

 

 

 

 

confirm-to-consentConfirm to Consent

View in Adobe Acrobat

View in Google Docs

 

 

 

 

patient-payment-agreementPatient Payment Agreement

View in Adobe Acrobat

View in Google Docs

 

 

 

 

confirm-to-consentArbitration Agreement

View in Adobe Acrobat

View in Google Docs

 

 

 

 

direct-paymentDirect Payment Form

View in Adobe Acrobat

View in Google Docs

 

 

 

 

TMD DisabilityTMD Disability Index

View in Adobe Acrobat

View in Google Docs

 

 

 

 

TMD Symptom IntensityTMD Symptom Intensity Scale

View in Adobe Acrobat

View in Google Docs

 

 

 

patient-case-historyAny Body Pain VAS

View in Adobe Acrobat

View in Google Docs

 

 

 

 

patient-case-history-p1Headache Pain

View in Adobe Acrobat

View in Google Docs

 

 

 

 

patient-case-history-p2Neck_Pain

View in Adobe Acrobat

View in Google Docs

 

 

 

 

patient-case-history-p3Patient Case History page 3

View in Adobe Acrobat

View in Google Docs

 

 

 

 

Any Body Pain VASAny Body Pain_VAS

View in Adobe Acrobat

View in Google Docs

 

 

 

 

Headache PainHeadache_Pain

View in Adobe Acrobat

View in Google Docs

 

 

 

 

Neck PainNeck_Pain

View in Adobe Acrobat

View in Google Docs