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310 E Hwy 50, Ste 2, O'Fallon, Illinois 62269

Same Day Appointments | Walk-in Availability

Mon, Wed, Fri: 11am - 1pm | 3pm - 6pm | Tues, Thurs: 9am - 3pm

To Request a New Patient Appointment call OR text:

Chiropractic New Patient Form

Please fill out the following form. (All Information is Confidential)

First Name

Today's Date

Date of Birth

Legal Guardian or Insured’s Name:

Last Name

Referred By

Age

Legal Guardian Date of Birth

Street Address

City

Region/State/Province

Postal / Zip code

Primary Phone

Secondary Phone

Email

Chief complaint and/or reason for today’s visit:

Do you have or have you had any of the following conditions:

Heart Disease

Cancer

Muscular Sclerosis

Spine Problems

Stroke

Heart Attack

High Blood Pressure

Arthritis

Diabetes

Mental Illness

Alzheimer’s

Asthma

I authorize the above Covered Entity(Doctor and Business Associates) to file claims to the insurance company(s) named above, on behalf of myself or my dependents. Additionally I authorize the Covered Entity to release medical documentation from mine or my dependent’s record, as required by my insurance company(s) to consider the payment of my claims. I agree to pay charges my insurance company does not cover, to include my out of pocket deductible.

Patient Signature (or responsible party)

Date

Insurance Information

Name of the Policy Holder (if it's different from the patient)

Birthdate (if it's different from the patient)

Upload Front of Insurance Card

Upload supported file (Max 15MB)

Upload Back of Insurance Card

Upload supported file (Max 15MB)

Thanks for submitting!

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Call to Schedule: 618-628-4488

Why Choose Us As Your O'Fallon Chiropractor?

We Accept

All Insurance

We are currently in network with Medicare, BCBS, Aetna, and Healthlink. We are NOT in network with Coventry, we ARE in network with UHC.

We will be happy to assist you in navigating your benefits before chiropractic care begins.

Affordable cash plans available too!

5-Star Rated

Chiropractic Doctors

Check out what our patients have said about our chiropractic services and Doctors.

-OR- leave us a review yourself and tell us about your experience with us and how we've helped.

State-of-the-art

Techniques

Our Doctors are specially trained to diagnose the health of your spine with motion study x-rays, the only chiropractic physicians in the area specialized in this technique.

Call or text us today!

Tel: 618-628-4488

310 E Hwy 50, Ste 2, O'Fallon, Illinois 62269

Same Day Appointments | Walk-in Availability

Mon, Wed, Fri: 11am - 1pm | 3pm - 6pm

Tues, Thurs: 9am - 3pm

Our O’Fallon, IL chiropractic office is a short drive from Scott Air Force Base, Shiloh, Belleville, Lebanon, Fairview Heights, Collinsville and all other Metro East St. Louis communities. We look forward to serving you.

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