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.

Paying for care.

How do you plan to pay?

Health insuranceMedicareAuto insurance (PIP)Self-pay

Insurance company *

Plan type

Member ID *

Group #

Insurer phone (back of card)

BIN

PCN

All of these are printed on your insurance card — the member ID and group number on the front, the customer service phone number on the back. BIN and PCN appear on many cards near the bottom; if yours doesn’t show them, just leave those blank.

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.

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. 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.