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Practice Name

Dunn Chiropractic Clinic

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Primary Location
301 NE Dunn Place
McMinnville, OR 97128
Phone: (503) 472-6550
Fax: (503) 472-1039

Office Hours

DayMorningAfternoon
Monday9am-12pm3pm-6pm
TuesdayClosedClosed
Wednesday9am-12pm3pm-6pm
Thursday10am4pm
Friday9am-12pm3pm-6pm
Saturday9am10am
SundayClosedClosed
Main Content

WELCOME TO THE CLINIC NEW PATIENT INTAKE

New Patient Information Worksheet:

Thank you for taking your time to fill this out. It will reduce your wait at the clinic.

PAST HEALTH HISTORY:

FAMILY HEALTH HISTORY:

SOCIAL HISTORY:

PATIENT HEALTH HISTORY WORKSHEET:

Please label the Area(s) of Todays Pain on the picture below and list the Quality of Your Pain (Sharp, Dull, Radiating, Aching, Burning, Numbness)

A

ACTIVITIES OF DAILY LIVING (ADL) WORKHSEET

(Please check the number which most closely describes your "Activities Of Daily Living" today)

REVIEW OF SYSTEMS

I have read the above information and certify it to be true and correct to the best of my knowledge, and hereby authorize this office of Chiropractic to provide me with chiropractic care, in accordance with this state statutes. If my insurance will be billed, I authorize payment of medical benefits to George Siegfried, D. C. / Dunn Chiropractic Clinic / Westgate Wellness for the services performed. You can sign this form when you come to the clinic. Please go to Printable Forms under New Patient Center for HIPPA and Terms of Acceptance. Thank you!

Patient or Guardian Signature: _______________________________ Date: ___________________

First Visit special price, for a limited time: Only $85 For Spinal Adjustment Only

(Excludes Nutritional Consultation, Nasal Specific or Decompression Treatment)


Sign-up using the form or call us at McMinnville: (503) 472-6550 to take advantage of this exclusive offer.

*For privacy purposes, your email will not be shared with anyone*


PRIVATE INSURANCE PATIENTS: Doctor is out of network. Patients pay at the time of service, we give you a receipt that you can submit directly to your carrier and be reimbursed directly for any coverage you may have.

Name: *
Email: *
Phone: *

Services We strive to provide complete care for our patients. Learn more about all the services we provide. Make An Appointment We will do our best to accommodate your busy schedule. Schedule an appointment today! Online Forms Our patient forms are available online so they can be completed in the convenience of your own home or office.

Testimonial

Dr. Siegfried is the best! Very profession yet personal. He uses a natural approach... My back and neck have been so bad that I couldn't even walk in to his clinic, but I would walk and with a few fi sits feel great again! Thanks for all that you do for Richard and I

- Laurie O. / McMinnville, OR

Office Hours

DayMorningAfternoon
Monday9am-12pm3pm-6pm
TuesdayClosedClosed
Wednesday9am-12pm3pm-6pm
Thursday10am4pm
Friday9am-12pm3pm-6pm
Saturday9am10am
SundayClosedClosed

Contact

  • Dunn Chiropractic Clinic
  • (503) 472-6550
  • Fax: (503) 472-1039
  • 301 NE Dunn Place McMinnville, OR 97128
  • Get Directions
  • Westgate Wellness
  • (503) 977-0055
  • Fax: 971-266-8369
  • 5319 SW Westgate Dr. Suite 152 Portland, OR 972221
  • Get Directions
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