Forms

We would like to take this opportunity to welcome you as a member of the Holland Chiropractic and Acupuncture office.

Enclosed is some important information for you to complete prior to your first visit. This information is essential for us to begin our assessment of your case. Please print and fill out the appropriate form below (note- some forms have multiple pages).  The following forms are in an Adobe PDF format and you will need a reader to open, read and print the forms.  The Adobe reader is free and can be downloaded at the following link:

https://get.adobe.com/reader/

It is important that the appropriate forms be completely filled out prior to your visit. Our office manager will tell you which forms are appropriate to your particular case. Please bring them with you on your scheduled appointment. In addition to the above documents, please bring in any recent diagnostic test results pertaining to your complaint (i.e., blood test, surgical report, x-rays, CT's, MRI's with reports, etc.).

Adult New Patient Intake Form  - https://my.onlinechiro.com/001...

From time to time we will need to gather health information from other health care facilities pertaining to you case or you may ask us to provide your information to other health care facilities.  In order to do so, we will need you to sign and provide us with authorization to obtain these records.  That is the function of this release form. 

Release of Information Form -  https://my.onlinechiro.com/001...

During your first visit, we will perform a comprehensive case history as well as a thorough orthopedic and neurological evaluation. Our goal is to become acquainted with your body's current state of function. By understanding your body's function, we can better determine the underlying cause of your condition and design a method of care specific to your circumstances.

Enclosed is some important information for you to complete prior to your first visit. This information is essential for us to begin our assessment of your case. Please print and fill out the appropriate form below (note- some forms have multiple pages).

The appropriate forms must be completely filled out prior to your visit. Our office manager will tell you which forms are appropriate to your particular case. Please bring them with you on your scheduled appointment. In addition to the above documents, please bring in any recent diagnostic test results pertaining to your complaint (i.e., blood test, surgical report, x-rays, CT's, MRI's with reports, etc.)

One Moment...

If you are an ACN, United Healthcare, United Healthcare of Colorado, Secure Horizons, or Medicare Complete Secure Horizons member, please complete the following Patient Notification Form, Back Index Form, and Neck Index Form needed by your insurance carrier. The forms can be downloaded by copying the links below to your address bar and printing out the form.    **COMING SOON **

Again, we welcome and appreciate you choosing this office for your healthcare.

If you have any questions please do not hesitate to call us at 303.422.7767.

Contact Us

Send us an email or Call us at 303-422-7767

Hours of Operation

Check out our schedule

Header

Monday:

8:00 am to 5:30 pm

Tuesday:

2:00 pm to 5:30 pm

Wednesday:

8:00 am to 5:30 pm

Thursday:

Closed

Friday:

8:00 am to 5:30 pm

Saturday:

By Appointment

Sunday:

Closed

Our Location

6295 W. 38th Avenue Wheat Ridge CO 80033

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