Online Forms

Online Forms

Bloomfield Total Health Center offers our patient form(s) online so they can be completed 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.
  • Email us your printed and completed form(s) at, fax us at (973) 338-4849 or bring it with you to your appointment.

New Patient Form

New Patient Office Form (Chiropractic and Physical Therapy)- Required

This lets us know the necessary information needed for your first and subsequent visits including insurance, billing and medical history forms. If you have any questions and/or concerns regarding your condition or in completing these forms, we can help? Let us know!

Download & Print Form (General Form)

Download & Print Form (PIP/Auto Accident Forms)

Download & Print Form (Worker's Compensation Form)

Acupuncture Form

New Patient Office Form (Acupuncture)-Required

This form will provide our licensed acupuncturist with the information needed to create the most effective treatment plan for you. 

PLEASE NOTE: The last two sections of this form are for the acupuncturist to complete during your initial appointment.

Download & Print Form

New Patient Office Form (Massage Therapy)-Required

This form provides vital information for our massage therapist to ensure that you are comfortable and safe during your massage session.

Call us today at (973) 338-3620 to learn about pricing and available times.

Download & Print Form

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