PLEASE COMPLETE THIS FORM
Have you been to a chiropractor before?
*
No
Yes
How many hours do you work each week?
*
0 - 20
20 - 40
40 +
Retired
How do you currently pay for medical care?
*
Out of pocket
Insurance
Medicare
Medicaid
Worker's Compensation
* Federal beneficiaries are not eligible
THIS OFFICE DOES NOT ACCEPT INSURANCE. ARE YOU WILLING TO PROCEED?
Select
Yes
No
WHERE SHOULD WE SEND YOUR CONFIRMATION?
Full Name
*
Email
*
Phone
*