Please download, fill out completely and bring these forms with you on your first visit.

1.  New Patient Intake Form


2.  New Patient Complaint Questionnaire


3.  Personal Injury (Motor Vehicle) Questionnaire


4.  Worker's Compensation Questionnaire



The above DOWNLOADS require the free Acrobat Reader from Adobe Systems. If your computer doesn't already have Acrobat installed, you may download it here
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4666 Commercial Street SE     
Salem, Oregon  97302  
Phone: (503) 399-7607
 

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Copyright 2006 by Michels Spinal Rehab  -  Dr. Geary J. Michels, DC, PC
New Patient Forms
In order to speed up your appointment, please print and fill out the appropriate forms.
Click to Download
Patient Testimonials
Form for collecting patient's address, phone number and insurance info
*All new patients must fill out this form*
Form for patients to describe their pain and areas of complaint
*All new patients must fill out this form*
Form for patients to describe their motor vehicle accident and corresponding complaints
*Only new patients that were involved in a motor vehicle accident must fill out this form*
Form for patients to describe their on the job injury and corresponding complaints
*Only new patients that had an on the job injury must fill out this form*