Online Forms

We look forward to having you in for your first appointment at Kambeitz Chiropractic Health & Wellness Center P.C. For your convenience, you can complete your new patient forms before your first visit, right here in your web browser.  If you prefer to print and handwrite your forms, you can scroll below to download PDFs of the new patient paperwork.


Marital Status

Insurance Information 

Dr. __________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Phone Numbers


Accident information

To whom have you made a report of your accident?

Patient Condition 

Type of pain:*
Please select at least one option
Does it interfere with your*
Please select at least one option
Activities or movements that are painful to perform*
Please select at least one option
Rate the severity of your pain on a scale from 1 (least pain) to 10 (severe pain)*
Please select one option
What treatment have you already received for your condition?
Please mark to indicate if you have any of the following
Work Activity
Are you pregnant?
Injuries/Surgeries you have had (Descriptions and Dates)

Medical Symptoms Questionnarie

Rate each of the following symptoms based upon your typical health profile for the past 30 days.

0 - Never or almost never have this symptom
1 - Occasionally have it, effect is not severe
2 - Occasionally have it, effect is severe
3 - Frequently have it, effect is not severe
4 - Frequently have it, effect is severe
















Patient Policies

Welcome to Kambeitz Chiropractic Health and Wellness Center P.C.

We here at Kambeitz Chiropractic are dedicated to providing you with the very best chiropractic care available today. This form will answer some of your questions and introduce you to the philosophy on which this practice is built. Our doctors and staff work together as a team to serve you. We emphasize patient education and advocate a natural approach to health. However, we do not diagnose disease or offer treatment for such conditions. Our goal as Chiropractors is the detection, correction and removal of the vertebral subluxation complex. Health and wellness are an ongoing effort and chiropractic should play a substantial role in your personal health care picture. The purpose of these agreements is to allow us to serve you more completely and to get the best results in the shortest amount of time. It is our experience that those patients who adhere to the following agreements get the best results. Please finish what you start or don't start. We enjoy working with people like you, who are committed to reaching their optimal health potential. 

Office Hours 

Our office is open Monday through Friday from 7:45am - 6pm. We are also open every Saturday from 8:00am to 1pm. There are specific times set aside for new patients and report of findings. For urgent cases, additional times are available by appointment only. Please note these office hours are subject to change. Our doctors attend and teach many seminars on Chiropractic and nutrition to provide you with the most current advances in Chiropractic. 

Payment of Bills

Payment for services is due at the time service is provided. Instead of paying for each visit you may prepay for your week's visits, or longer term prepay plans are available. This will save you time and reduce writing checks or using your credit card on each visit. We do not bill patients. If we are forced to bill you, you will receive a service charge and 21% interest per annum. This clinic is out of network with all insurance companies. Insurance companies will be billed according to your plan benefits for out of network. Insurance patients agree to assign their benefits to Kambeitz Chiropractic. Any amounts that are not paid by the insurance company are the sole responsibility of the patient and due immediately. 

Missing or Changing Appointments 

Appointments should be scheduled with the front desk. Please keep your appointments for your health's sake, as each adjustment adds to the next. We have set up a specific course of care for you. A certain number of visits in a set amount of time is required for us to get the results we both desire. If you need to cancel or change your appointment we ask that you please do so within 24 hours so that another patient may take your place. There will be a $20 fee assessed for any missed appointments. Regardless of how many appointments are scheduled for you each week, please note that it is the frequency of visits that count and not the days. It is your obligation to make up a missed appointment within 7 days of any cancellations. 

Eating Plans and Food Supplements 

Eating plans should be followed and supplements taken if recommended. Any problem you may have with these recommendations should be communicated. We do not prescribe, but will, at times, make recommendations for weight loss or to help speed your recovery. We offer classes and one on one personal nutritional consultations. 

Health Care Class

The purpose of requiring all new patients to attend this special workshop is to enlighten you about your body, especially the spine and nervous system. We have found that patients attending this class respond faster. Attendance in this class is mandatory within the first 2 weeks of care. If you cannot attend a class, arrangements must be made to receive a private class with the doctor. If you have a friend or relative who may be contemplating whether or not chiropractic care may be of help to them, this is an excellent opportunity for them to find out about chiropractic. 

Personal Training 

We offer personal training by appointment and have group exercise classes scheduled throughout the week. Please let the front desk know when we can book your training session. Class schedules available at the front desk. 


We offer massage therapy by appointment only. The types of massages we offer are Swedish, Deep Tissue, Neuromuscular, Maternity, and Sports. Please contact the front desk to book your appointment. 

Laser Therapy 

Laser therapy is a light therapy that can penetrate as low as 4.5 inches beneath the skin to treat a variety of conditions both acute and chronic. The laser stimulates the cells of the affected tissue healing and cellular regeneration. This therapy is used for pain management, inflammation control, improved blood supply and lymphatic drainage. 

Our Responsibility to You 

The staff at Kambeitz Chiropractic value your time and will do our utmost to have minimal waiting time when you come for an appointment. We are here to serve you. Please speak with your doctor about any upsetting matter. We see your comments as helping us to help you and others. You can expect to be treated in a courteous and professional manner at all times. The doctors and staff have the highest regard for your health and comfort. We will make every effort to adhere to our appointment schedule. However, we ask that you please understand if we run behind due to an emergency or other situation that is beyond our control. In the interest of providing you with the very best in health care, we will explain your condition as clearly as possible and outline a care plan for you. We here at Kambeitz Chiropractic look forward to serving you and your health care needs. 

Referrals and Questions 

Your referrals are appreciated. Telling others about chiropractic will change their lives. Ask us about our complimentary consultations for your friends and family. As you have questions about your health care or the health of a friend or loved one, please call or ask us. We appreciate the opportunity to be of service to you. 

Adjusting Children 

Bring your children in for check-ups and chiropractic care. No one is too young. If we watch our children for a few hours it is easy to understand how their spines can become subluxated. If left uncorrected, more serious problems will occur later. Children under the age of one are treated at no charge if the child's parent(s) are being adjusted. 

I have read the above and I understand and accept these policies

Thank you for taking the time to fill out this form.

Printable New Patient Forms

Kambeitz Chiropractic Health & Wellness Center, P.C. offers our patient form(s) online so you can complete it in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

This let's us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form

Medical Questionnaire - Required

Fill us in with your medical history so we can better plan for your care in the clinic and any conditions that may affect your treatment protocols.

Download & Print Form

Patient Policies - Required

Please review and sign our patient policies form before starting treatment at our clinic.

Download & Print Form

New Patient Pediatric Health History Form

This let's us know the history and current state of your child's health. What questions, concerns, goals, regarding your child can we help you with? Let us know!

Download & Print Form

New 8WW Participant Forms

Patients who will be participating in our 8 Weeks to Wellness program have a medical symptoms questionnaire and health satisfaction survey to fill out prior to starting the program.

Download & Print Form

Download the Free AdobeReader®