Schedule Appointment

Patient Information:

Last Name: *

First Name: *

Gender: *

D.O.B: *

Choose the Patient's Language: *
English Spanish Creole

Patient Contact Information:

Phone: *

Email:

Address: *

City: *

State: *

Zip Code: *

Chiropractic / MRI facility where exam is being performed — Keyword: *

Facility Provider Last Name: *

Facility Provider First Name: *

Facility Name: *

City where exam is being performed: *

Attorney's Name: *

Date of Injury: *

Choose the Location of Patient Exam: *
Office Visit Home Visit - Text Message

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.

Patients that attempt to check in 30 minutes, or more before their scheduled appointment, or 8 hours after their scheduled appointment shall require their EMC rescheduled by notifying customer service via our contact us page.