We Look Forward to Helping You

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Please fill out this form as much as you can so we can give you the best estimate of what we will need to collect from you before your first appointment.

Email *

Legal first name *

Legal last name *

Best phone number to call you at: *

How did you hear about COOR Wellness? *

From an existing patient at COOR Wellness

I saw your sign

Google Search for 'Chiropractor'

Google Search for a Specific Issue

Insurance Directory

Another health care provider referred me to COOR Wellness

Other:

What are you needing help with? *

General Wellness

Back Pain

Neck Pain

Headaches

Auto Accident

Plantar fasciitis

Hip Pain

Rip Pain

Shoulder Pain

Carpal Tunnel Syndrome

Knee Pain

Running Injury

Cycling/Mountain Biking Injury

Crossfit or Weight Lifting Injury

Pickle Ball Injury

Other:

I plan to pay for my services by: *

I will be a self pay patient

I will use my health insurance (please text front/back photos of your card and driver's license to 970-712-6059)

I will use my auto accident insurance (please ask your agent if you have a policy called "Med Pay")

I will use my worker's compensation insurance (please gain a referral)

I will use Medicare (Medicaid does not cover chiropractic care in Colorado)

I will ask COOR Wellness to accept me as a Financial Hardship

I would like to barter goods or services for my care (a signed agreement will be necessary)

Other:

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