310 E Hwy 50, Ste 2, O'Fallon, Illinois 62269

Same Day Appointments | Walk-in Availability

Mon, Wed, Fri: 11am - 1pm | 3pm - 6pm | Tues, Thurs: 9am - 3pm

To Request a New Patient Appointment call OR text:

618-628-4488

Massage New Patient Form

Please fill out the following form. (All Information is Confidential)

First Name

Date

Last Name

Birthday

Home Address

City

Region/State/Province

Postal / Zip code

Primary Phone

Occupation

How did you hear about us?

How many glasses of water do you drink a day?

Are you pregnant?

Yes

If yes, how far along?

Any medical conditions or medications we should be aware of? Comments/explanations:

Emergency Contact Information:

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relation?

Today’s Experience

Would you like the massage therapist to wear a mask?

Yes

Have you ever received a professional massage/bodywork before?

Yes

Would you like a full body massage:

Yes

Concentrate on specific areas

Please explain

Do you prefer:

Heavy Conversation

Light Conversation

Silent Relaxation

Preferred pressure (1 being light pressure, 5 being firm pressure, 10 being deep pressure):

At any time during the massage, you may choose to stop or modify the treatment. If you have any questions or concerns, please talk with the massage therapist. During the treatment you will be draped with sheets. The draping will only uncover the area being worked on at the time. You may choose to remove or leave clothing according to your comfort level. You may experience soreness or discomfort the day after your massage. If this happens, it is important to let the therapist know so that your next treatment can be modified. Your therapist will have suggestions on how to prevent the discomfort from occurring. I understand that massage or bodywork should not be construed as a substitute for medical treatment, and that I should see a physician, chiropractor, or other qualified medical specialist for any physical or mental ailment. I agree to keep all information up-to-date on all changes in my health and understand that there shall be no liability on the massage therapist’s part should I fail to do so. I also understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate termination of the session, and I will be liable for payment of scheduled appointment. The massage therapist reserves the right to refuse service to anyone for any reason. I have read, understood, and agree to massage therapy treatment.

Your Signature

I declare I have NOT experienced any COVID related symptoms in the past 14 days.

Thanks for submitting!

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Call to Schedule: 618-628-4488

Why Choose Us As Your O'Fallon Chiropractor?

We Accept

All Insurance

We are currently in network with Medicare, BCBS, Aetna, and Healthlink. We are NOT in network with Coventry, we ARE in network with UHC.

We will be happy to assist you in navigating your benefits before chiropractic care begins.

Affordable cash plans available too!

> 618-628-4488

5-Star Rated

Chiropractic Doctors

Check out what our patients have said about our chiropractic services and Doctors.

-OR- leave us a review yourself and tell us about your experience with us and how we've helped.

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State-of-the-art

Techniques

Our Doctors are specially trained to diagnose the health of your spine with motion study x-rays, the only chiropractic physicians in the area specialized in this technique.

Call or text us today!

> 618-628-4488

Tel: 618-628-4488

310 E Hwy 50, Ste 2, O'Fallon, Illinois 62269

Same Day Appointments | Walk-in Availability

Mon, Wed, Fri: 11am - 1pm | 3pm - 6pm

Tues, Thurs: 9am - 3pm

Our O’Fallon, IL chiropractic office is a short drive from Scott Air Force Base, Shiloh, Belleville, Lebanon, Fairview Heights, Collinsville and all other Metro East St. Louis communities. We look forward to serving you.

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