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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.

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

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

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.

THIS ---->https://gchiropractic.com/new-patient-center/online-forms.html

Office Hours

Monday8:30 - 1:003:00 - 6:00
Tuesday8:30 - 1:00
Wednesday8:30 - 1:003:00 - 6:00
Thursday12:00 - 6:00
Friday8:30 - 2:00
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30 - 1:00 8:30 - 1:00 8:30 - 1:00 8:30 - 2:00
3:00 - 6:00 3:00 - 6:00 12:00 - 6:00


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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