New client intake

Tell us what brings you in.

Share the basic information our team needs to understand your request and coordinate the next step. Digital X-ray and MRI are available when clinically appropriate and properly ordered.

Please keep this initial form brief. Do not include Social Security numbers, payment-card information, medical records, or detailed diagnostic history.

Your information

Full legal name

EmailPhone

Preferred location

Reason for today’s visit

What brings you in today?Primary areas affected (select all that apply)

You may select more than one area—for example, both neck and lower back.

How did this begin?

Imaging

Have you already had imaging performed? Yes No

Submitting this form does not order imaging or confirm an appointment. A qualified professional must determine whether additional imaging is appropriate.

Head or face
Neck
Shoulder or arm
Upper back
Lower back
Hip or pelvis
Knee or leg
Hand or foot
Other or unsure