Health is nothing more than a few simple disciplines, practiced every day; while disease is simply a few errors in judgment, repeated every day. It is the accumulative weight of our disciplines and our judgments that leads us to either health or disease.

New Patient Paperwork

We're committed to your chiropractic health! Currently Accepting New Patients

We believe that EVERYONE can benefit from great Chiropractic health!

Now is a good time to improve the health of your spine,

because the health of your spine

affects the health of your whole body.

Our office is currently accepting new patients.

To make an appointment – please call:

Eureka – (636)938-9310        

New Client PaperworkDon’t like filling out paperwork in the waiting room? You can download the forms below.

If you are seeing us as a result of an:

Auto Accident

Other Accident, or

Work Related Injury

you will need different forms.

Please call our office at 636-938-9310.

Please click the following for the seven pages of patient paperwork that you will need.

1 Patient Registration

2-patient-registration-meaningful-use

3-clinical-record

4-health-survey

5-health-survey-body-diag

6-consent-hipaa-addtlhipaa-jan2017new

TEXT consent patients

 

(To download the forms, you may need to have Adobe Reader installed on your computer. If you do not have Adobe Reader, you can easily download and install a free copy by visiting https://get.adobe.com/flashplayer/. Just follow the instructions provided.)  Or, if you prefer, we can fax the paperwork to you.

We look forward to meeting you and assisting you in your healthcare needs!
(Please NoteIf you would rather not complete new-patient paperwork in advance, we kindly ask that you arrive 20 minutes prior to your scheduled appointment so that you can fill out these forms in the office.)

Please bring the following items with you also:

  • A list of your primary care doctors names / addresses / phone numbers.
  • Current Insurance Card(s) – Please note that all Insurances are contracted differently.  Therefore, if you have any questions about your coverage, please contact your Insurance Provider prior to your visitAlso, if a REFERRAL is required, please contact your Primary Care Physician to ensure that you can get a referral.
  • Current Photo ID.
  • The names and dosage amounts of all medication(s), or supplements you are currently taking.
  • A copy of your family medical history.

 

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