New Patient Paperwork

We have our new patient paperwork available online for download. Completing as much of this paperwork before coming into the clinic for the first time will save you 15-20 minutes of time sitting in the waiting room while filling out the forms. While this is not required for an office visit, it is here for your convenience.Please use the following links to print and fill out your insurance coverage and patient health history forms. The forms are formatted in Adobe Acrobat, in order to view them you will need Adobe Acrobat Reader installed on your computer.

 

If you do not have Adobe Acrobat Reader you can click here to download it FREE. Get Abode Reader

 

If you have any questions regarding any of the forms, leave that section blank, bring into the office with you on your first visit and our kind and friendly staff will guide you through any difficulties with the paperwork.

 

REQUIRED REGISTRATION PAPERWORK FOR ALL NEW PATIENTS

All new patients to the clinic are REQUIRED to fill out this paperwork.  Please click the Download button

for to download the appropriate registration form.

 

Back Pain Paperwork

 

If you have back pain, please download and fill out the Back Pain Registration.

 

Neck Pain Paperwork

 

If you have neck pain, please download and fill out the Neck Pain Registration.

 

Back AND Neck Pain Paperwork

 

If you have neck and back pain, please download and fill out the Neck and Back Pain Registration.

 

Headache Paperwork

 

If you are experiencing a headache, please download and fill out the Headache Disability Index and the Neck Pain Registration. If this is your "First and/or Worst" sudden headache you have ever experienced, please call 911 or go to the Emergency Room.

 

Worker's Compensation Paperwork

 

If you have been injured at work, please download and fill out the Workers Compensation History and one of the applicable registration forms listed above (i.e. if you had a back injury and it is going through Workers Compensation, download the Workers Compensation History and the Back Pain Registration above).

 

Personal Injury Questionnaire

 

If you have been injured in a motor vehicle accident or slip/fall injury, please download and fill out the Personal Injury Questionnaire and one of the applicable registration forms listed above (i.e. if you have neck pain after a motor vehicle accident and the injury is going to be covered through motor vehicle insurance, download the Personal Injury Questionnaire and the Neck Pain Registration above).

Office Hours

Monday - Tuesday

9:00 AM - 6:00 PM

Wednesday

5:30 PM - 7:00 PM by appointment

Thursday - Friday

9:00 AM - 6:00 PM

Saturday

9:00 AM - 12:00 PM by appointment only

Sunday

9:00 AM - 12:00 PM by appointment only

Address

214 Center St.

Bloomsburg, PA 17815
hanswbotteschdc@gmail.com

Tel: 1-570-204-9302
Fax: 1-570-317-2594

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