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Online Forms

Barneveld Family Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive at our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.

Patient Health Questionnaire and Health History Form - Required

These forms allow us to better understand your health history and current state of your health. In addition to what questions, concerns, goals, regarding wellness you may be interested in discussing. 

To save time at your initial appointment you may choose to complete these forms and bring them with you! 

Health History Form

Patient Health Questionnaire Form


Patient Admittance Form - Required

This form provides us with the necessary information to setup your patient account, and process your insurance claims if applicable.  Please complete and bring to your initial appointment.

New Patient Form OR https://patients.acomhealth.com/barneveldfamilychiro


Authorization to Treat Minor 

Required if a patient is under 18 years of age. The accompanying parent or guardian must fill out this form to authorize treatment.

View & Print Form


Privacy Practices & Disclosure Authorization - Required

Notice of Privacy Practices

View & Print Form

After reviewing this document, a patient is asked to sign the following disclosure and release form which acknowledges our privacy practices and authorizes our clinic to treat you and submit your information for marketing purposes and insurance claims.

Locations

Find us on the map

Office Hours

Our Regular Schedule

Monday:

8:00 - 8:30 am

10:30am - 5:30pm

Tuesday:

8:00 - 8:30 am

10:30am - 5:30pm

Wednesday:

8:00 - 8:30 am

10:30am - 5:30pm

Thursday:

8:00 - 8:30 am

10:30am - 3:30pm

Friday:

8:00 - 8:30 am

10:30am - 3:30pm

Saturday:

By Appt.

Closed

Sunday:

Closed

Closed

Testimonials

Reviews By Our Satisfied Patients

  • "Thank you for taking such good care of my family and me. The adjustments keep me grounded, and the good laughs keep me blissful."
    Kimberly S. Clark, Mount Horeb, WI
  • "I first went to Dr. Kimberly due to the ease of scheduling and due to her location being so close to my home, daycare, and my child's school. I keep going to Dr. Kimberly because of her individualized treatments, her willingness to experiment with new treatments, and her continuous knowledge for what she does. I have recommended several family and friends to Barneveld Family Chiropractic and they agree!"
    Melissa Schlimgen, Ridgeway, WI
  • "The Barneveld Chiropractic Clinic is the only place I will go. I have a plate in my neck and she is the only chiropractor who I trust to help me relieve my pain! She takes special care of my needs! Thank You Dr Kim! You are the best!"
    Sue Ellen Steen, Ridgeway, WI