VSC Wellness Center New Patient Inquiry 2026
If you are interested in receiving services from our clinic this form will help us get you started and answer any of your question.
Patient Information
Name of person seeking care
*
First Name
Last Name
If the prospective patient is a minor, please include the name of a parent/ guarding:
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Format: (000) 000-0000.
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Social Security Number (last 4 digits)
Name of the primary care provider of person seeking care:
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Insurance Information
We can verify your insurance and give you the specific coverage based on your particular plan. This allows us to more accurately estimate your out-of-pocket costs.
Type of insurance
*
Medicaid/ Healthy Indiana (if you check this you can skip the next section)
Traditional Medicare
Medicare Advantage Plan (Humana/ Aetna/ United)
Other major medical: Anthem, BCBS, United Healthcare, Cigna, Ambetter, etc
Other insurance not listed
I have no health insurance (you can skip the next section)
Primary Insurance Co
Policy No
Group No
Primary Insurance Phone No (located on the insurance card)
Format: (000) 000-0000.
Subscriber's Name (person who carries the insurance)
First Name
Last Name
Date of Birth of insurance subscriber
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
Secondary Insurance Co (if you do not have a secondary insurance skip the next few sections)
Policy No
Group No
Secondary Insurance Phone No
Format: (000) 000-0000.
Subscriber's Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Subscriber's Relationship to Patient
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Appointment request information:
Our office is open all day Mondays, Wednesdays, and Thursdays. Please select the day/ days of the week that work best for you
*
Monday
Wednesday
Thursday
I am flexible
Our office hours are from 9-1:30 and 3-6 each day. Please select the time/times that works best for your schedule.
*
9-11am
11am-1-30pm
3-4:30pm
4:30-6pm
I have a flexible schedule
Types of services you are interested in (select all that apply):
*
Chiropractic care
Chiropractic care- prenatal
Chiropractic care for my infant/ child
Blood work analysis/ Funtional medicine assessment
Physical therapy
Lymphatic drainage
Concussion treatment
Massage therapy- therapeutic
Massage therapy- relaxation only
I am unsure
Other
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Specific Questions we may answer for you:
Reason for seeking care:
Let us know a summary of your complains below.
*
Any specific questions we may answer for please list below. If you have no specific questions just type "none"
*
After reviewing your information someone from the office will be contacting you. Please list the prefered contact method.
*
phone call
text
e-mail
Submit
Should be Empty: