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Online Forms

Dr. Russell Janssen offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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) (fax 727-796-9139) or bring it with you to your appointment.
  • Please bring your photo i.d. and insurance card to your appointment.
  • If you have recently had any x-rays, MRIs, CT scans, or blood tests, please bring the report(s) or have your healthcare provider fax us a copy to 727-796-9139 so Dr. Janssen can review the report(s) during your appointment.

New Patient Forms

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

Please Download and Print Both Forms

Download & Print Form - New Patient Intake

Download & Print Form - HIPAA Form

New Patients With Blue Cross Blue Shield or Cigna

To speed up your visit and reduce your paper work, please fill out the appropriate Functional and Pain Assessment forms for your areas of complaint.

Download & Print Form - Ash New Patient Health Status

New Patients With United Health Care

To speed up your visit and reduce your paper work, please fill out the appropriate Functional and Pain Assessment forms for your areas of complaint.

Download & Print Form - UHC Insurance Forms





Auto Accident Intake Forms - Required if Auto Accident

Download & print each form:

Accident History
Assignment of Benefits
Benefit Payout
Disclosure
Benefits Release
Treatment Notification
Back Pain
Neck Pain


Medical Records Release Form - Optional

This form can be filled out if you have any other person you would like us to communicate with about your healthcare and treatment. This includes obtaining information from other physicians, getting x-rays or other imaging reports, blood test results, or other medically pertinent information to your treatment with Dr. Janssen. If you would like us to be able to communicate with a spouse or significant other (including appointment times, treatment plan, or payment arrangements, etc.) you must also fill out this release form.

Download & Print Medical Records Release Form



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Office Hours

Monday:

11:00 am-6:00 pm

Tuesday:

7:00 am-10:00 am

Closed

Wednesday:

11:00 am-6:00 pm

Thursday:

11:00 am-6:00 pm

Friday:

7:00 am-12:00 pm

Closed

Saturday:

By Appt.

Closed

Sunday:

Closed

Our Location

*THE PATIENT AND ANY OTHER PERSON RESPONSIBLE FOR PAYMENT HAS THE RIGHT TO REFUSE TO PAY, CANCEL PAYMENT OR TO BE REIMBURSED FOR PAYMENT OF ANY OTHER SERVICE, EXAMINATION OR TREATMENT WHICH IS PERFORMED AS A RESULT OF OR WITHIN 72 HOURS OF RESPONDING TO THE ADVERTISEMENT FOR FREE, DISCOUNTED, OR REDUCED FEE SERVICES, EXAMINATION OR TREATMENT. OFFER NOT VALID FOR MEDICARE OR MEDICAID PATIENTS.