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Gonstead Chiropractic Service
  • Appointment Request
  • 424-278-4880

Dr Gs Gonstead Chiropractic Clinic

Ultimate Health and Wellness Chiropractic Care

  • New Patients
    • Online New Patient Forms
    • Payment Options
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    • Gonstead Chiropractic Videos
    • Rapid Release Therapy
  • Meet Dr. G
    • Testimonials
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  • Contact Us
  • New Patients
    • Online New Patient Forms
    • Payment Options
  • Services
    • Gonstead Chiropractic Videos
    • Rapid Release Therapy
  • Meet Dr. G
    • Testimonials
  • Products
  • Blog
  • Contact Us

Online Forms

Dr. G’s Ultimate Health and Wellness Mobile Care offers our patient forms online so they can be completed in the convenience of your own home or office, before your appointment date.

New Patient Health History Form – Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Step 1 of 4

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  • MM slash DD slash YYYY
  • Tell Us About Yourself....

  • Please enter a number less than or equal to 99.
  • Contact Information

  • Home Address

  • About The Location Of Your Appointments

  • About Your Job

  • Emergency Contact Information

  • Thank You For Choosing Us!

  • Tell Us About Your Symptoms

  • This is your chance to tell "your story" of the symptoms that you are experiencing. Please explain what your symptoms are, how they started, how they're progressing, what makes them better/worse, etc...
  • About Your Main Complaint

  • Tell Us About Your Medical History

  • Name of medicationReason for taking 
  • Family Health History

  • Some health problems are hereditary. Please describe any health issues your parents or siblings are experiencing (or have experienced).
  • General Policies

    Locations we service: Although we service most of Indiana, when and where we schedule appointments is completely up to the discretion of Dr. Giuliano. Appointment verification: We verify every appointment by text message unless an alternative contact method is requested. If we do not receive a response prior to your appointment, we will consider the appointment canceled and a cancellation fee of $50.00 will be charged. Be prepared and on time: We will be prepared and on time for your appointment and ask the same of you. You have a dedicated time slot for your appointment that starts at your scheduled appointment time and ends 30 minutes from that time regardless of when treatment commences. We ask that you wear comfortable, relaxed-fitting clothes during your appointment. Canceled or missed appointments: Please give 24 hr or "day before" notice for an appointment that needs to be canceled or rescheduled. If appropriate notice is not given, you will be charged a $50.00 cancellation fee. Right of refusal: We reserve the right to refuse service to anyone at any time for any reason.
  • Financial Policies

    Fees: Our fees are located on the home page of our website and are stated as $80 per individual, per initial visit. By clicking "I agree" at the end of this form, you are agreeing to the fees as listed. Payment methods: All payments are due prior to, or at the time of your appointment. Payments can be made by cash, local check or credit card. Checks not honored by your bank will be subject to an additional $30 fee. Health insurance: We do not accept health insurance and do not assist with any attempt at reimbursement for our services. Refunds: Completed appointments are not refundable. Receipts: Receipts are available by email when requested. Additional fees: Additional fees may apply for appointments outside of our normal service area or normal hours. However, we are 100% transparent with our fees and you will never be charged an additional fee without discussing and agreeing to these fees with Dr. Giuliano.
  • Privacy Policies

    Our privacy policies can be found on here our website. You can also request a copy of privacy policies which will be send by email only. Also see our Practice Policies.
  • Informed Consent For Treatment

    Congratulations on choosing one of the safest and most natural healthcare programs available! Please read the following statement carefully as it pertains to your informed consent to be treated. "I hereby acknowledge that all information submitted pertaining to my case is true and correct to the best of my knowledge. I understand that I am responsible for full payment of all services rendered by Marco Giuliano Chiropractic, LLC. I have read and understood the preceding statements and hereby consent to myself or those I claim as dependent voluntarily participating in chiropractic care and/or physiotherapeutic rehabilitation procedures as deemed appropriate by my doctor. If at any time I decide that I am unwilling to engage in these procedures, I reserve the right to inform my doctor of such and not participate in these forms of evaluation and treatment. I understand that results are not guaranteed and that I have the opportunity to discuss the purposes and risks associated with all recommended evaluation and treatment procedures at any time."
  • This field is for validation purposes and should be left unchanged.

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Giuliano Chiropractic

Dr. Marco Giuliano
Gonstead Chiropractor
424-278-4880

1111 N Brand blvd st 402
Glendale, Ca 91202

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Our Story

Dr. Marco Giuliano discovered the miracle and vitality of chiropractic care through his own personal experiences as a college football player and amateur body-building state champion. Chiropractic care saved Dr. Giuliano’s life as an athlete.

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