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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:

Signatures

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

Habits

Have you ever suffered from:

Our Locations:



We have designed affordable cash plans that compete and sometimes beat your insurance plans. By joining our ChiroHealth USA Network, we can offer you significant discounts. You will be surprised at the savings. So, even if we are not a provider with your insurer, it will probably pay to give us a call.

Sign-up using the form or call us at one of the numbers below to learn more about us and our plans to restore your health and save you money.

THIS ---->https://fosteringwellnessnet.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours


Brandon Hours
 
Monday 7:30-12:00 2:00-6:00
Tuesday CLOSED CLOSED
Wednesday 7:30-12:00 2:00-6:00
Thursday CLOSED CLOSED
Friday 7:30-12:00 2:00-6:00

Rutland Hours

Monday 7:30-12:30 2:00-6:00
Tuesday CLOSED 2:00-6:00
Wednesday 7:30-12:30 2:00-6:00
Thursday CLOSED CLOSED
Friday 8:00-12:30 CLOSED

Randolph Hours

Monday 8:30-12:30 2:00-6:00
Tuesday 7:30-12:00 2:00-6:00
Wednesday 8:30-12:30 2:00-6:00
Thursday 7:30-12:00 2:00-6:00
Friday 8:30-12:00 2:00-6:00

Springfield Hours

Monday 7:30-12:00 2:00-6:00
Tuesday CLOSED CLOSED
Wednesday 7:30-12:00 2:00-6:00
Thursday 7:30-12:00 2:00-6:00
Friday CLOSED CLOSED

Testimonial

I have started a new lifestyle, I have been eating really well, taking vitamins and being more active. Coming here as given me a new outlook on life. I'm pro-chiropractic for life!

Sara B
Rutland, VT

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