Schedule Appointment

Patient Information:

Last Name: *

First Name: *

Gender: *

D.O.B: *

Choose the Patient's Language: *
English Spanish Creole

Patient Contact Information:

Phone: *

Cell Phone: *

Address: *

City: *

State: *

Zip Code: *

MRI, Chiropractor Name, Facility, Location — Keyword: *

Choose the Location of Patient Exam: *
Office Visit Home Visit / Patient is out of MRI or medical facility - Patient Text Message

* Notify the patient of the evaluation and our intent to schedule the exam

Chiropractor's Last Name: *

Chiropractor's First Name: *

Facility Name where exam is being performed: *

City where exam is being performed: *

Attorney Name, Firm Name — Keyword: *

Attorney Info* POLICY

No Attorney

Attorney's Last Name: *

Attorney's First Name: *

Firm Name: *

Date of Injury: *

Patient Insurance Information:

Auto Insurance Company: *

Claim #:

Policy #:

Either claim Number or Policy Number is a required field* POLICY

Requested Appt. Date: *

Preferred Appt Time: *

All patient benefits are verified prior to EMC reports being sent out. Please attempt to input accurate insurance and claim info, in order to avoid any delays in reporting.

Patient Information:

Patient Contact Information:

Patient Insurance Information:

Duplicate Patient?