Fletcher Heights Chiropractic
20783 N. 83rd Ave, Ste #110
Peoria, AZ 85382
Phone:
623-209-2000
Fax: 623-209-2001
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Dr. Nicholas Jay, D.C.
Dr. George Kukurin, D.C.
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Please download the forms below, and print them
out. Fill them in as completely as you possibly can before coming to
the office for your first visit. You will need Adobe Acrobat Reader
to read, and print out these files. You can get the latest version
of Adobe Acrobat Reader by clicking on the image below:

Patient Registration Form
HIPAA Consent Form |