New Patient Forms

We are excited that you have chosen us for your medical care and look forward to meeting you.  The New Patient Form is a form that you can fill out and submit online for your convenience.  You can also save some time by printing out and completing the other forms in advance of your appointment so we can expedite your visit.  If possible, please fax them to 281-332-7593.

1. EHR Intake Form

2. New Patient Form

3. Notice of Privacy Practices: HIPAA form

4. At least one of the following Pain Indexes.  If you are not sure what forms you need please call the office and we will be more than happy to help you or you can wait until you get to the office before filling out the pain indexes.  If you have multiple problems please fill out more than one index.

Back pain: This includes upper, middle, lower back pain as well as leg pain beginning in the back and moving into the leg.
Back pain Index
Back pain Index (Spanish)

Neck pain: This includes neck and arm pain that starts in the neck and moves down the arm.
Neck Pain Index
Neck Pain Index (Spanish)

Lower body pain: includes hip, leg, knee, ankle, or foot.
Lower Extremity Functional Scale
Lower Extremity Functional Scale (Spanish)

Upper body pain: includes shoulder, arm, elbow, forearm, wrist, or hand.
DASH
DASH (Spanish)

For those patients scheduled for a nutrition examination please fill out our Nutrition Policy PRIOR to your appointment. Please note, nutrition exams must be scheduled specially by our team and can not be worked into a regular appointment.

 

James Heintz, DC, CCSP
Brian Sansalone, DC, CCSP
Tanner Brusnighan, DC

League City Chiropractic
1200 East Main Street
League City, TX 77573
Phone: 281-332-3428 
Fax: 281-332-7593

Office Hours: 
Monday 8-6:30
Tuesday 8-8
Wednesday 7-6:30
Thursday 8-8
Friday 7-4:30
Sat 9-2 

 

Payment Options: 
Payment Methods Accepted

 

  • Aetna
  • Blue Cross Of Texas
  • First Health Network
  • Great West Healthcare
  • Humana
  • Medicare
  • PacifiCare
  • UniCare
  • United Healthcare