Request an appointment

     

One of the most important aspects of patient care here at Haines Chiropractic is to always put the patient's needs first, and we recognize that convenience is large part of great customer service. Therefore, we now offer our patients the ability to arrange for an appointment online.   

Just let us know what days and times work best for you, and a staff member will schedule your appointment and call you back to confirm the date and times.  It's that easy!

 

Part I.  Patient Information: 

1. What is your name?  

 

2. If the appointment is for another family member, what is the patient's name and relationship to you? 

 

 

3. What is the age of the patient? 

 

3. Are you (or your family member) a new patient or a former patient of Haines Chiropractic?

                      New Patient                           Former Patient

 

Part II. Appointment Request  

Please fill out one of the boxes below to request either our first available opening (left box) or a specific day and time (right box).

    Please schedule an appointment for me during the following times:

1. What weekday works best for you? 

    Monday      Tuesday      Wednesday        Thursday (mornings only)      Friday         Any day

2. What time do you prefer? 

I prefer a morning appointment.  

I prefer an afternoon appointment.  

Please schedule me for your first available appointment, either mornings or afternoons.

 

Part III.  Additional Information.  What is the reason for the appointment? (back or neck pain, accident, headaches, wellness check, etc.)  You may also use this space to provide us with any additional information you feel will be helpful to us in serving you.

 

Part IV.  Conformation:  We will schedule your appointment at the time you requested and call you to confirm the appointment date and time.

What is the best telephone number to reach you at during the day?

Daytime Telephone

Alternate Telephone

 

If you need to reach us to discuss your appointment, please call our office at 254-3999.  We will be glad to assist you!

Thank you for allowing us to serve you!

 

 

 

  
 

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