New Patient Paperwork

If you’re a new patient with Proactive Chiropractic, welcome! We’re proud to be part of your journey toward pain relief through chiropractic care.

To help serve you better and to make your first visit with us as productive as possible, we’ve compiled a list of four forms you’ll need to fill out prior to your appointment. Download them using the links below, fill them out and bring them with you.

  • All forms are PDF files. You will need AdobeReader® to view them.
  • If you do not already have AdobeReader® installed on your computer,
    Click Here to download.
  • Download the necessary form(s), print them out and fill in the required information.
  • Bring the necessary form(s) to your appointment.

This form helps us obtain your demographic information quickly. It also helps us gather information about your pain and past medical history so we can create a treatment plan that works best for you.

This form gives us permission to treat you and solidifies our promise to discuss any risks involved with your treatment.

This form outlines how your health information will be used in our office and serves as your consent for its use.

This form gives Dr. Khlebopros permission to perform x-rays during your visit.

New Patients:


8:00am - 6:00pm

12:00pm - 6:00pm

8:00am - 6:00pm

12:00pm - 6:00pm

8:00am - 1:30pm

(Open Every Other Week)

9:00am - 12:00pm

Emergency Only

Proactive Chiropractic and
Rehab Center

11010 South Tryon Street #112
Charlotte, NC 28273
(704) 504-1770