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54 The Legends Parkway, Suite 158 Eureka, MO 63025
636-938-1010
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Advanced Chiropractic and Nutrition offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • If you choose to fill out our New Patient Paperwork and submit it to our office online, you will need to do so from a desktop or laptop computer (no ipads or tablets).  Just follow the first link below, "Patient Intake Form- Computerized Intake" and answer all questions accurately.  At the bottom of the form you will be asked to sign (hold down the left mouse button while using your mouse to sign your signature).  When you are finished, please click on the "Submit" button to assure transmission to our office.
  • If you would like to cut down on your paperwork once you come to the office, you can download the other necessary form(s):
    • Patient/Insurance Form
    • HIPAA Form
    • Consent to Treat Form

Just print them out, fill in the required information, and then fax us your completed form(s) or bring them with you to your appointment.


New Patient Health History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

PATIENT INTAKE FORM - COMPUTERIZED INTAKE

Patient/Insurance Information Form

Confidential Case History Form

Patient Health History Form

HIPPA Form

Motor Vehicle Accident Form

Consent to Treat Form

Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form



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