Take2 Healthcare | Take2 Menu logo | Dayton Ohio Chiropractor, Acupuncture & Nutrition Center
Make An Appointment

Ph: 937-433-3241  /  Fax: 937-496-5468   |   5777 Far Hills Ave.  Dayton, OH 45429   | 

                                                                                                                                     Office Hours: Monday & Wednesday: 8a-5p, Tuesday: 8a-4:30p, Thursday & Friday: 8a-12p

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Patient Forms

Please ensure all paperwork is completed by the time you arrive to your appointment. Some forms take longer than others to complete, so if you plan on doing them in the office, just make sure you arrive early enough to complete everything required. Your appointment confirmation email will tell you how early you’d need to arrive.

If the paperwork is not completed by the time you arrive, we may need to reschedule your appointment.

Acupuncture Patients

Complete all forms below

  • Acupuncture (Female) – Please print, fill out and bring to your appointment
  • Acupuncture (Male) – Please print, fill out and bring to your appointment
  • HIPAA Consent – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com
  • Patient Permissions Form (optional) – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com

Chiropractic Patients

Complete all forms below

  • Patient Questionnaire – Please print, fill out and bring to your appointment
  • HIPAA Consent – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com
  • Patient Permissions Form (optional) – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com

Nutrition Patients

Complete all forms below

  • Patient Symptom Survey (PLEASE READ!) – You will receive a separate email for the PSS (can also be called Health History Form). That email does not come from Take2 Healthcare. Call us with any questions or issues with this form
  • Patient Questionnaire – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com
  • HIPAA Consent – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com
  • Patient Permissions Form (optional) – This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com

Thermography Patients

*NEW PATIENTS – For Breast Series, Fill out all forms below
*RETURNING PATIENTS – For Breast Series, Fill out the first 2 forms only

Breast Thermography

    Half or Full Body Thermography

    *NEW PATIENTS – For Half or Full Body Series, Fill out all forms below
    *RETURNING PATIENTS – For Half or Full Body Series, Fill out the first 2 forms only

    Release of Medical Records

    If you are a current patient and need personal health information sent to an outside provider, please fill out the form below.

    • Release of Medical Records – Releasing Take2 medical information to another provider or office. This can be filled out electronically, but must either be printed and brought in or emailed to: mail@take2healthcare.com