Chiropractic Associates, P.C.

Online Pre-Admission Forms and Appointment Request

Our goal is to make your visit to Chiropractic Associates as enjoyable as possible. For your convenience, you have the option of downloading our pre-admission forms (which are also available at our admitting desk). After filling out the forms, you should drop them off at our admitting area when you arrive for your appointment.

For more information, please call (402) 488-1500.

Chiropractic care is for everyone. Fill out the following forms when you have decided to become a new patient.

Pre-Admission Forms

New Patient

	Required of all new patients. This will provide our office necessary information for your first visit.
	Entrance Application
	Financial Agreement
	History of Illness/Injury/Pain
	HIPPA Declaration

Auto/Personal Injury

Complete this form if you were injured in an accident involving an automobile, whether you were driving or a passenger.

Personal Injury

Complete this form if you have been injured and want to seek medical attention.

Worker’s Compensation

Workman's Compensation provides coverage for injuries resulting from work related activities.

Appointment Request

To request an appointment, please complete the form below. Please be sure to provide your phone number (with area code) so that we can call you to confirm your appointment. You may also call (402) 488-1500 and ask to make an appointment.

Chiropractic Associates is open Monday through Friday and Saturday mornings.

NOTE: Appointment requests must be submitted at least 24 hours in advance. Submitting the request DOES NOT schedule an appointment. Our office will call you at the number you provide to confirm your request and schedule the appointment.

Online Appointment Request

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Please complete the form in its entirety. You must complete all the required fields noted in *red. Incomplete submittals may delay processing.

PATIENT'S NAME

*First Name:
Middle Initial:
*Last Name:

PATIENT'S HOME ADDRESS

*Line 1:
Line 2:
*City:
*State:
*Zip Code:
*Home Phone:

	Check this box if the patient's name is someone other than yourself.
	Your name, if different from patient's name:

INFORMATION FOR CHIROPRACTIC ASSOCIATES' OFFICE
The following information is required in order to request an appointment:

Gender:

Patient ID # (if known)

Request appointment with:

	REASON FOR APPOINTMENT
	In order for us to schedule your appointment, please provide a short description of the reason for your visit.

	APPOINTMENT TIME PREFERENCES
	We will make every effort to accommodate your preference for an appointment. Appointment availability is also contingent on chiropractor availability.

Select Date	Select Time

	CONTACT INFORMATION
	*Contact Phone: Alternate phone number if unavailable at home phone number.

	Area Code - - Ext.

Best time to call you to confirm an appointment:

Please Note: This form is not on a secure server and the information could be viewed by an outside source. By submitting information, you certify that you are at least 18 years old.

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Complete Diagnosis
We specialize in discovering the underlying cause of an individual's condition or concerns and then fully explain these findings and offer a wide range of treatment options.

Effective Care
Chiropractic health care is popular, effective, natural and affordable. The range of patients successfully cared for is from 3 days old to well over 100 years of age.

Lifetime Benefits
Hundreds of people benefit from expert, comfortable, Chiropractic treatment, acupuncture, personalized training, physical therapy, nutritional assessment and counseling, as well as high tech rehabilitation every week.

Innovative Wellness Strategies
Chiropractic Associates offers innovative wellness strategies for all ages and occupations based on Dr. Donkin's popular book:

Peak Performance
Body & Mind: How To Make Your Body Last A Lifetime


		Morning	Afternoon
Office Hours	Monday	7:30 - 12:30	2:00 - 6:00
	Tuesday	8:00 - 12:30	2:00 - 5:00
	Wednesday	7:30 - 12:30	2:00 - 6:00
	Thursday	8:00 - 12:30	2:00 - 5:00
	Friday	7:30 - 12:30	2:00 - 6:00
	Saturday	9:00 - 11:00

Chiropractic Associates, PC is an official ProAdjuster clinic. Click on the ProAdjuster logo above for more information.


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A Good Night's Sleep (For You!)

Simple changes to your sleep position can ensure sounder snoozing. By Meghan Rabbitt. Parenting Magazine, October 2007.

The article includes simple changes for better shut-eye from
Dr. Scott Donkin. Read more...

Wellness Links

Back Vitalizer™

Paying for Chiropractic Care

Wholefood Farmacy

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Chiropractic Associates, P.C., 5540 South Street, Suite 200, Lincoln, Nebraska 68506
Phone: 402-488-1500 Fax: 402-488-6651 or E-mail us.