Forms to Download

Home » Forms to Download

Complete the forms below
Before your first Chiropractic or Nutrition visit with Dr. Pearce, please download, print, and complete the appropriate form(s) from the links below. Filling out the paperwork thoroughly ahead of time in a relaxed atmosphere can help you focus, and save you time and stress!



Consultation / New Patient Packet

Daily Record of Food Intake

Symptom Survey Form



Patient Basic Information Packet

Patient Health Questionnaire

Injured in a car accident? Please fill out these additional forms:

Auto Accident Packet

HIPPA Forms Packet (required by law to read and sign)

Notice of Patient Privacy

Consent to Use PHI

Patient Authorization


You can send the completed forms to us in one of three ways:

  • The forms can be faxed to: 903-757-9390

  • Scan and e-mail to:

  • Bring to our office: DrPearceWellnessCare 123 Gilmer Rd  Ste 3 Longview, TX  75604