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New Patient Intake Form


If you have been (or would like to) scheduled for an exam and consultation please download the form below, print it, fill it out and bring it with you to the office. This will ensure speedier processing and optimize your experience here at Bergman Family Chiropractic.


New Patient Form


The form is in PDF format.  If you don’t have Adobe Reader on your computer, you can download it FREE by clicking the button below.

Adobe Reader


Call 714-962-5891

John Bergman
Dr. Bergman was launched into chiropractic by a devastating accident that nearly ended his life. At 30 years old Dr. Berman was a hard working single dad when he was hit by a speeding car that left him with 2 fractured legs, a fractured skull and chest, bruised liver and heart... (see the welcome page for more details)
John Bergman
John Bergman
John Bergman

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  1. Ryan Watchel says:

    I am just woundering once we fill out this fourm do we just walk in to your office when ever with it? or do we book a apointment online or the phone?

  2. maria grechishkina says:

    Dr. Bergman – my daughter is 13 and a half years old. She has and S curve scoliosis. During the 6 months period the upper curve increased from 18 degrees to 25 degrees and lower curve from 15 to 18 degrees. The doctor at the Children’s Hospital of the University of Pennsylvania recommends Boston brace. I wonder if you could recommend an alternative treatment plan. I also need to understand how often after the initial consultation you need to see your patients. i am asking because we live on the East Coast and would need to fly to CA for the consultations. Is anybody of your followers practice in Pennsylvania? Thank you, Maria

    • Hi Maria
      The Boston brace will not help, To stop and correct scoliosis focus in on getting her natural curves, she will be either missing or have a reversed neck curve, have her lay on her stomach with her elbows on the floor and her chin in her palms (like kids watch tv) this is a passive exercise and by getting her neck curve back this will slow or stop the progression of her thoracic curve.
      I don’t know of any corrective Chiropractor in Pennsylvania, I have a list of questions to find a good one:
      1. Do you take x-rays? (essential to find the subluxations)
      2. Do you get listings off of x-rays? (shows where to adjust)
      3. Do you take post x-rays to document structural changes made?
      4. Are your treatment goals to reshape and restore the natural curves?
      5. Are you familiar with correcting disc injuries?
      6. Do you work on post surgical patients?
      7. Can you reverse arthritis?
      For my protocol I examine and may be able to give a report on the first day, this will give the minimal amount of correction that we can get, then the adjustments for the typical scoliosis is 3 times a week for 90 days, 6 weeks minimum before a post x-ray is done to document the structural changes.
      Make sure you stop her vaccinations and get her on a non-GMO diet the neuro toxins will cause the scoliosis to progress
      I will help in anyway I can
      She will get better
      Dr B

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