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