Patients Forms

Active ChiroCare!

Make An Appointment

For your convenience, please complete forms below. Email completed form to or bring in 15 minutes before your appointment time

Health Insurance/Self Pay Form:

Auto Accident Injury Form:

For Returning Patients:

Our Insurance Policies


Unfortunately accidents occur that causes injuries to areas you are aware of and unaware of until it is too late. Fortunately for you, our doctors are knowledgeable with constant continuing education and experience in providing a thorough evaluation to ensure all areas are addressed as to avoid future concerns as a result of your injuries. Inform us if you have been injured and we will guide you back to health.


We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk has years of experience and will be happy to assist you.


We at Active ChiroCare do not want finances to determine your health. Therefore, we have affordable payment options to allow you to receive the treatment that you need to pursue your optimal health goals. Also for your convenience we accept, cash, personal checks, MasterCard, Visa and/or discover cards.

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