WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

(773) 545-2233

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

$149 for initial consultation, chiropractic exam, 1 set of x-rays and report of findings.
Call or email!

Click the button below to view our new patient offer!

NEWWWW seamanchiro.com_1.jpg

Office Hours

Day
Monday9:30 am-12:30pm3:30 pm-7:00pm
TuesdayClosedClosed
Wednesday09:30am-12:30pm3:30 pm-7:00pm
Thursdayclosed3:30-7:00pm
Friday9:30 am-12:30pmClosed
Saturdayclosedclosed
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:30 am-12:30pm Closed 09:30am-12:30pm closed 9:30 am-12:30pm closed Closed
3:30 pm-7:00pm Closed 3:30 pm-7:00pm 3:30-7:00pm Closed closed Closed

What can we help you find?