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Online Forms

PLEASE READ BEFORE COMPLETING FORMS:

Please click on the link below to fill out the New Patient Intake Form. At the bottom of the form click on 'Submit Form' when you are finished filling out the form. (*Please note- if you are not completing forms on a touch screen, you will need to use the mouse as a pen to sign the bottom. Hold down the left click & sign.)

These forms cannot be submitted from a cell phone.

If you are using a Mac, please use the Google Chrome browser.

If you are unable to submit the form before your appointment please come in 15 min early to complete the form on our IPad.

If you are unable to submit the form before your appointment please come in 15 min early to complete the form on our IPad.

Click Here To Complete New Patient Forms


Please make note of our Cancellation/Missed Appointment Policy:

• If you are unable to keep an appointment, as a courtesy to other patients and our staff, please give us 24 hours notice. We reserve the right to apply a $25 charge to your account for each cancellation received less than 24 hours in advance. We also reserve the right to apply a $65 charge to your account for each appointment missed when we do not receive prior notice (no call, no show). The patient will be responsible for payment regardless of future appointment schedule.

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Locations

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Office Hours

CHANGES TO REGULAR SCHEDULE: Office will be closed Thursday 11/23 & Friday 11/24.

Jeurink Family Chiropractic and Wellness Center

Monday:

9:00 am-12:30 pm

2:00 pm-6:00 pm

Tuesday:

Closed

Wednesday:

9:00 am-12:30 pm

2:00 pm-6:00 pm

Thursday:

2:00 pm-6:00 pm

Friday:

9:00 am-12:30 pm

2:00 pm-5:30 pm

Saturday:

Closed

Sunday:

Closed