Initial Intake Questionnaire

As of 2019, we are in-network providers with Medicare only. We are no longer in-network with major medical insurance. However, you can take advantage of our discounted rates, provided the payment is made on the day the treatment is rendered (a.k.a. time-of-service). Oftentimes, these rates are actually lower than your in network rates. If you would like us to check your Medicare information before your scheduled appointment, please submit your information in the comments box or call with the information at least two business days ahead of your appointment.

Patients Name*

Name

Email*

Phone*

Date of Birth*

Date of Last Visit*

Have you been exposed to or in contact with anyone with COVID in the past 14 days?*

COVID pre-screening questions for the saftey of patients and staff

Yes
No

Have you tested positive or had COVID symptoms in the past 14 days?*

COVID pre-screening questions for the saftey of patients and staff

Yes
No

Type of service you are requesting*

Reason for Visit*

Doctor or Provider you'd like to see*

Message/Comments*

West University Wellness - Houston, TX

Chiropractic

Pregnancy

Pediatrics

Massage Therapy

Acupuncture

Post-Partum

Nutritional Counseling

Telehealth

Sports Injuries

COVID-19 UPDATES