113 West 5th Street
Eureka, MO 63025
Patient Intake Paperwork
We are excited that you are ready to take a giant step forward in wellness by visiting our office. When you walk in our doors…you’ll know we are different. Chiropractic, Sports Performance, and so much more!
We focus on YOU!!!
Once your appointment is made, simply click the Intake Paperwork Button and complete the New Patient Intake. You will need to fill out the complete intake prior to your appointment. If you have any issues completing the intake paperwork in advance, no problem! We kindly ask that you arrive 20 minutes prior to your scheduled appointment so you can fill it out on one of our I-Pads in the office.
Are you visiting us as a result of an Auto Accident, or Work Related Injury?
Please call us at 636-938-9310 because you will need different forms.
Please bring the following items with you:
A list of your primary care doctors names / addresses / phone numbers.
Current Insurance Card(s) – Please note that all Insurances are contracted differently. If you have any questions about your coverage, we encourage you to contact your Insurance Provider PRIOR TO YOUR VISIT.
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.