Adult Male

Here are the forms for your initial chiropractic visit.  These files are downloadable which means you can simply print them and then fill them out.  Please remember to sign where requested and bring these forms with you to your appointment.  We will also need to see your insurance card (if applicable) at that time. 

Protecting your personal information is very important to us.  We comply with HIPAA and all other privacy protocols.  Read our complete privacy policy here. 

All adult males please complete these 2 forms:

New Patient Intake Form

Fee Policy

 

*If you are a new Medicare patient, please complete the first 2 forms plus these 2:

*  FRI

*  ABN

 

**If you are coming to the office because of a motor vehicle collision, complete the first 2 forms plus the following:

**  PI Questionnaire

**  FRI

**  Pain Drawing

**  Visual Analog

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  • Chiropractic Lifestyle Center

  • Meg Simans, D.C.
    David J. Powell, D.C.
    991 NE Riddell Rd
    Bremerton, WA 98310
    (360) 373-2225

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