Chiropractic Intake Form

Create a Login Account (optional)

New Users / Returning Users CLICK HERE to setup or return to your account for this form. Creating an account enables you to return to this form and your submitted results. An account will also enable you to partially complete this form and return later to finish the form. The account you establish is only for this form.

Thank you for choosing to become a Wellspring Centre for Body Balance client. Please fill out the following health and wellness record as completely and accurately as possible. If you have yet to schedule your New Patient Series please contact the Wellspring Centre for Body Balance office at (541) 482-2021.

First Name *

Last Name *

Nickname

Address *

City *

State *

ZIP *

Home Phone
(xxx-xxx-xxxx) *

Cell Phone

May we send free text appointment
confirmations to your cell phone?

Yes

No

Cell Carrier:

Email Address
(we will not distribute your email address)

Confirm email address

Please check below if you DO NOT want us to use your email for the following reasons:
(Check all that apply)

Appointment Confirmation	Private Health Communication
Email Newsletter

Sex *

Female

Male

Occupation *

Marital Status *

Birth Date
(MM-DD-YYYY) * +

Spouse's (Partner's) name
(if applicable):

Are you seeking care with us because
you have filed a personal injury claim? *

Yes

No

Does your health insurance have chiropractic benefits?
(Please bring your insurance card, we can help you submit charges to your insurance company with that information) *

Yes

No

Not Sure

Emergency Contact *

Emergency Phone
(xxx-xxx-xxxx) *

Relationship *

How did you hear about us?

Who may we thank for your referral?

Primary Care Physician

Specialty

Other current healthcare providers