Select Life Chiropractic

Life is full of choices…Select yours.

Online Forms and Downloads

We are providers for most insurance plans. Please contact us or refer to your insurance plan to find out if we are in your network.

NEW PATIENT INTAKE FORM

Please complete the intake form as best you can. If you have questions or are uncertain about how to answer something, please feel free to ask us!

Infant/Child Assessment Form

If you're bringing your child in for an appointment, please complete this form to provide us with some additional information.

Patient Summary Form

If you have MEDICA or United Healthcare as your primary insurance, please fill out the "Patient Summary Form" and the "Keele Screening Tool" in addition to our new patient intake form. Depending on your condition, you will also need to fill out the appropriate index form.

Keele Screening Tool

If you have MEDICA or UHC, Please download and fill out this form in addition to the "Patient Summary" and our new patient intake form.

Neck Index

If you have MEDICA or UHC insurance and currently suffer from a neck condition, please download and complete this form.

Back Index

If you have MEDICA or UHC insurance and currently suffer from a back condition, please download and complete this form.

Shoulder, Arm, and Hand Form

If you have MEDICA or UHC insurance and currently suffer from a shoulder, elbow, or hand condition, please download and complete this form.

Lower Extremity Form

If you have MEDICA or UHC insurance and suffer from a knee, ankle, leg, or foot condition, please download and complete this form.