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7810 Ballantyne Commons Pkwy #101

Charlotte, NC 28277 US

(704) 542-6500

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Online Forms

Gallagher Chiropractic and Wellness offers our patient intake forms 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.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This lets us know the history and current state of your health and saves you time by allowing you to fill out the paperwork in the comfort of your own home. We have two options.

Option 1:  Download and print forms at home, fill them out and bring them to the office.  Use the following links.

Click here do download & print New Patient Intake Forms
Click here to download & print Neck Pain Index Form
Click here to download & print Back Pain Index Form

Option 2:  Online forms.  Click on the following link and fill out all your information online.  If you choose this option be sure to separate different issues.  For example if you have neck and low back pain, when prompted, choose the area of the neck that is bothering you and answer the appropriate questions.  Then choose an additional complaint and choose the area of the back that is the problem area and answer the questions for that issue.  This will make sense as you go through the questions.  

Let us know if you have any questions.

Click here to fill out your information online



Auto Accident and Workers Comp Information Form

Please complete the following form in addition to the above forms.

Click here to download and print Accident Information Form


Contact Gallagher Chiropractic and Wellness in Charlotte  Today!

If you haven't already made an appointment and aren't scheduled to see us yet, Contact us or call us at (704) 542-6500 to schedule an appointment today. 

Gallagher Chiropractic and Wellness is located 7810 Ballantyne Commons Pkwy, #101 Charlotte, NC 28277.

Receive a no charge consultation with Dr. Gallagher!

Sign-up using the form or call us at (704) 542-6500 to take advantage of this exclusive offer.

Office Hours

Our Regular Schedule

Monday:

8:30 am-1:00 pm

3:00 pm-6:00 pm

Tuesday:

8:30 am-1:00 pm

Wednesday:

8:30 am-1:00 pm

3:00 pm-6:00 pm

Thursday:

12:00 pm-6:00 pm

Friday:

8:30 am-2:00 pm

Saturday:

Closed

Sunday:

Closed

Locations

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Testimonials

Reviews By Our Satisfied Patients

  • "This was my second episode of symptoms so bad that I could not work. The first time I turned to an orthopedic clinic for help. It was very slow going for relief. I had always heard good things about chiropractic treatment. The second time around I called Dr. RICHARD GALLAGHER at GALLAGHER Chiropractic after 6:00pm at his office. He saw me the next morning and afternoon and continued to treat me with adjustments and heat therapy. I was walking straight within a few days and pain free within a few weeks. I highly recommend GALLAGHER Chiropractic."
    Pamela D. / Charlotte, NC

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