If this could be an emergency — severe chest pain, sudden weakness or numbness, loss of bladder or bowel control, or a serious head or neck injury — call 911 or go to the nearest emergency room now. This form isn’t monitored around the clock.

About you.

First name *

Last name *

Date of birth *

Mobile phone *

How did you find us?

Street address

City

ZIP

Your visit.

What would you like to be seen for? *How long has this been going on?

Under a week1–4 weeks1–6 months6+ monthsIt comes and goes

Have you had chiropractic care before?

YesNo, first time

Is this related to a recent auto accident?

YesNo

Heads up: Florida auto-insurance (PIP) rules put a time limit on seeking care after a crash — the sooner you’re evaluated, the better, for both your health and your claim. We handle the documentation; we’re not attorneys.

When would you like to be seen?

As soon as possibleNext dayIn a couple of daysNext week

This just helps us prioritize verifying your insurance — appointments aren’t booked or guaranteed until we call you back.

Paying for care.

How do you plan to pay?

Health insuranceCash pay

Insurance carrier *

Front of your insurance card *

Take or choose a photoInsurance card — front — still empty

Flat on a table, all four corners in frame. No typing member IDs — we read everything we need straight from the photo.

Back of your insurance card *

Take or choose a photoInsurance card — back — still empty

Same idea — the back usually carries the claims and customer-service details we need.

One quick photo ID.

A photo of your government-issued ID *

Take or choose a photoGovernment ID — still empty

Driver’s license, state ID, or passport — it’s how we make sure your chart is really yours.

What happens next: a member of our team verifies your benefits with your insurer, then calls you back with your expected cost and to find you a time — usually within one business day. Nothing is scheduled or charged until you talk to a person. Your first visit runs about 1 hour 15 minutes — Dr. Moore takes her time on new-patient exams, going over your full history before any adjustment.

We ask only for what we need to verify benefits and call you back. This form is sent securely to our staff and isn’t stored on the website; your ID and insurance-card photos go straight to our in-office computer — never to the website, never by email. Please save the details of your health history for your visit. If anything urgent changes, call us at (941) 220-6993.

Let’s get you started.

Thirty seconds beats phone tag.