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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:


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


Have you ever suffered from:

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Office Hours

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
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


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

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