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Practice Name

Bruns Chiropractic and Massage Therapy Clinic

Primary Location
371 Union Street
Bangor, ME 04401
Phone: 207-947-1199
Fax: 207-942-8729

Office Hours

Day
Monday7 - 122 - 5
TuesdayclosedClosed
Wednesday7 - 122 - 5
ThursdayClosedClosed
Friday7 - 122 - 5
SaturdayClosedClosed
SundayClosedClosed
Main Content

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

Patient Data

Mailing Address

Type of Payment Coverage

Insurance Information

*If an auto accident, please provide:

Date ____________________

Symptoms - List location and describe each symptom (ie. pain, ache tingling, numbness, burning etc)

Personal Medical History

Since you were last here, have you

Family Health History

Habits

Have you ever suffered from:

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.

Date ____________________

Patient's signature _______________________________________________

Spouse's or guardian's signature __________________________________

New Patients Welcome: Call 947-1199


 


 

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Services, Forms, & Testimonials

Services We strive to provide complete patient care. Learn more about the services we provide. Online Forms Our patient forms can be completed in the convenience of your own home or office. Testimonials See what our patients have to say about Bruns Chiropractic and Massage Therapy Clinic!

Office Hours

Day
Monday7 - 122 - 5
TuesdayclosedClosed
Wednesday7 - 122 - 5
ThursdayClosedClosed
Friday7 - 122 - 5
SaturdayClosedClosed
SundayClosedClosed
Day
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7 - 12 closed 7 - 12 Closed 7 - 12 Closed Closed
2 - 5 Closed 2 - 5 Closed 2 - 5 Closed Closed

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