New Patient Forms

We are accepting new patients for chiropractic and acupuncture in the Edwardsville, IL area. To make your first visit smoother, please download the appropriate packet below and complete it prior to arrival.

To schedule a new patient appointment, please call us at phone 618-692-0000 or contact us.

Chiropractic and Acupuncture New Patient Form

Chiropractic and Acupuncture New Patient

The Chiropractic and Acupuncture New Patient packet consists of the following forms:

Patient Information, Consent to Chiropractic Services, Current Problem History, Symptom Survey, Confidential Health History, Acknowledgment of Receipt of HIPAA Privacy Notice, and Financial Disclosure.

HIPAA PRIVACY NOTICE

HIPAA Privacy Notice

Please review this notice carefully. It describes how your medical information may be used and disclosed and how you may gain access to that information.

Non-Discrimiation Policy, Section 1557


Brueggeman Chiropractic Center does not tolerate the discrimination of any patient on the basis of race, color, national origin, sex, age, disability, pregnancy, or gender identity. Dr. Emily Brueggeman serves as the compliance coordinator for Section 1557, and any complaints or grievances should be brought directly to her attention.

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