If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

new_patient_special_1.png
 

request_appointment_04d.png

THIS ---->https://thinkchiropracticfirstcom.chiromatrixbase.com/new-patient-health-history-form.html

Office Hours

DayMorningAfternoon
Monday8 am - 12:30pm2:30pm - 6:00pm
TuesdayClosed2:00pm - 5:00pm
Wednesday8 am - 12:30pm2:30pm - 6:00pm
Thursday9 am - 12:30pm2:30pm - 6:00pm
Friday8 am - 12:00pmClosed
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8 am - 12:30pm Closed 8 am - 12:30pm 9 am - 12:30pm 8 am - 12:00pm Closed Closed
2:30pm - 6:00pm 2:00pm - 5:00pm 2:30pm - 6:00pm 2:30pm - 6:00pm Closed Closed Closed

Testimonial

My back pain was why I started with chiropractic care.  I had shots and pills before and didn't want them anymore.  I couldn't ride in the car even a little ways let alone on a trip to see my grandkids.  I gave up gardening because I couldn't bend.

The whole office is so friendly you make friends instantly.  My overall health has changed because not only is my back great, I can ride 3 hours without stopping.  I'm so happy because I don't hurt.  I think my whole attitude is better.  Thank you!

Judy B.

Rochester, MN

Newsletter Sign Up