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Practice Name

Progressive Chiropractic

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Primary Location
11694 Seward Hwy Suite C
Seward, AK 99664
Phone: (907) 224-8680
Fax: (907) 224-8910

Office Hours

DayMorningAfternoon
Monday9:00am6:00pm
Tuesday9:00am6:00pm
Wednesday9:00am5:00pm
Thursday9:00am5:00pm
Friday9:00am5:00pm
SaturdayClosedClosed
SundayClosedClosed
Main Content

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Contact Us!

Contact us using the form or call us at (907) 224-8680

Name: *
Email: *
Phone: *

Testimonial

I have benefited tremendously from the chiropractic care I received from Dr. Petersen.

John Doe -
Seward, AK

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We will do our best to accommodate your busy schedule. Schedule an appointment today!

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Services

We strive to provide complete care for our patients. Learn more about all the services we provide.

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Contact

Progressive Chiropractic
11694 Seward Hwy Suite C
Seward, AK 99664
Get Directions
 
  • Phone: (907) 224-8680
  • Fax: (907) 224-8910
  • Email Us

Office Hours

DayMorningAfternoon
Monday9:00am6:00pm
Tuesday9:00am6:00pm
Wednesday9:00am5:00pm
Thursday9:00am5:00pm
Friday9:00am5:00pm
SaturdayClosedClosed
SundayClosedClosed
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