Intake Form

Name *

Address *

Phone number *

Email address *

Date of birth *

Gender *

Reason For Visit *

Please select at least one option.

Personal Injury (Car Accident, Slip & Fall, Attorney Referral, etc).

Worker's Compensation

Wellness Program & Consultation

Have you ever received chiropractic care before? *

Where is your pain? *

Please select at least one option.

Head

Neck

Mid Back

Low Back

Arms and/ or Legs

Are you currently taking any medications? *

Which service or services are you interested in? *

Please select at least one option.

Chiropractic Adjustment & Modalities

Diagnostic X-Rays

Nutritional & Holistic Counseling

Dry Needling Therapy

Physical Therapy

Therapeutic Massages

Insurance *

Please select at least one option.

Auto Accident or Worker's Compensation Claim

Aetna

Blue Cross/ Blue Shield

Christus Health Plan-Louisiana

Cigna

Medicare

Medicaid (United Healthcare/ La Healthcare Connections)

UMR

Other

Out of Pocket Expense

Member ID/ Claim Number *

Additional questions or comments

Wellness Chiropractic & Holistic Care