Useful Forms

Let’s Discuss Your Health Concerns

Phone: (616) 698-0046

Address: 7101 Broadmoor Ave SE, Caledonia, MI 49316

Hours:

Mondays 8:30 AM 6:00 PM
Tuesday 9:00 AM 6:00 PM
Wednesday 7:30 AM 5:00 PM
Thursday 8:30 AM 6:00 PM
Friday 7:30  AM 12:00 PM
Schedule Appoinment

New Patient forms for Chiropractic Care

Please select from the list below for the appropriate form. Each form will open in a separate window which you can print for your convenience.

Fast Track Scheduling Form:

This form can be used by other physicians/medical facilities to refer patients to any of our doctors at Burkhart Chiropractic.

New Patient Initial Evaluation Form:

Please complete this form prior to the first time you come into our office for services.

Authorization to Release Medical Records:

This form needs to be signed by the patient in order for us to release x-rays and medical records from our office to other health care providers. This form can also be used by us to request X-rays and medical records be released to us from other health care providers.

HIPAA Authorization:

This form needs to be signed by the patient indicating that they have been made aware that their information will not be shared without their consent. Under HIPAA guidelines, there are also other rules and regulations involving the patient’s legal obligation to pay their co-pays or deductibles.

FABQ Questionaire:

This form gives the doctor an understanding of how the patient’s pain affects their activities of daily living. There are two sections to the FABQ, the first being related to general daily activities and the second primarily related to questions about work. The patient should indicate how much they agree with each question or statement.

Confidential Application for Evaluation & Treatment:

This form serves as the most complete source for our doctors at Burkhart Chiropractic to evaluate and treat the patient and, as such, will be kept confidential at all times. It includes patient information and their medical history as well as the office policies for missed and canceled appointments.

Let’s Discuss Your Health Concerns

Phone: (616) 698-0046

Address: 7101 Broadmoor Ave SE, Caledonia, MI 49316

Hours:

Mondays 8:30 AM 6:00 PM
Tuesday 9:00 AM 6:00 PM
Wednesday 7:30 AM 5:00 PM
Thursday 8:30 AM 6:00 PM
Friday 7:30  AM 12:00 PM
Schedule Appoinment

Your path to wellness starts here.

Schedule My Appointment
Call Now: (616) 698-0046