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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

Please Describe Your Current Symptoms:

Please describe your symptoms:

Insurance Information

*If an auto accident or personal injury, please provide attorney information (if applicable):

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.

Name of the Insured _____________________________________________

Signatures

Patient's signature _____________________________________Date

Spouse's or guardian's signature __________________________________ Date

Medical History

Please complete

Family History

Habits

Do you have a history of any of the following?

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New Patients Welcome: Call 947-1199


 


 

of the Chiropractor 
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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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