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Online Forms

Dr. Russell Janssen offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) (fax 727-796-9139) or bring it with you to your appointment.
  • Please bring your photo i.d. and insurance card to your appointment.
  • If you have recently had any x-rays, MRIs, CT scans, or blood tests, please bring the report(s) or have your healthcare provider fax us a copy to 727-796-9139 so Dr. Janssen can review the report(s) during your appointment.

New Patient Forms

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Please Download and Print Both Forms

Download & Print Form - New Patient Intake

Download & Print Form - HIPAA Form

New Patients With Blue Cross Blue Shield, Cigna, United Health Care, or American Speciality Health

To speed up your visit and reduce your paper work, please fill out the appropriate Functional and Pain Assessment forms for your areas of complaint.

Download & Print Form - Neck Index

Download & Print Form - Back Index

Download & Print From - Scoring Neck & Back Index

Download & Print Form - Arm/Shoulder/Hand Disability Assessment

Download & Print Form - Lower Extremity Functional Scale

Download & Print From - Medical Necessity Review Form


Auto Accident Intake Forms - Required if Auto Accident

Download & print each form:

Accident History
Assignment of Benefits
Benefit Payout
Disclosure
Benefits Release
Treatment Notification
Back Pain
Neck Pain


Medical Records Release Form - Optional

This form can be filled out if you have any other person you would like us to communicate with about your healthcare and treatment. This includes obtaining information from other physicians, getting x-rays or other imaging reports, blood test results, or other medically pertinent information to your treatment with Dr. Janssen. If you would like us to be able to communicate with a spouse or significant other (including appointment times, treatment plan, or payment arrangements, etc.) you must also fill out this release form.

Download & Print Medical Records Release Form


Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

Download & Print Form - Member Wellness Registration



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