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 AdobeReaderĀ® 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.

Daily Patient Health Questionnaire Form - Required

These form 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 form and bring them with 

Patient Health Questionnaire Form


New Patient Admittance Forms - 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

Dr. Kimberly

Monday

8:00 - 8:30 am

10:30am - 5:30pm

Tuesday

10:30 am - 3:30 pm

Wednesday

8:00 - 8:30 am

10:30am - 5:30pm

Thursday

10:30 am - 5:30 pm

Friday

8:00 - 8:30 am

10:30am - 3:30pm

Saturday

By Appt.

Closed

Sunday

Closed

Closed

Dr. Kimberly

Monday
8:00 - 8:30 am 10:30am - 5:30pm
Tuesday
10:30 am - 3:30 pm
Wednesday
8:00 - 8:30 am 10:30am - 5:30pm
Thursday
10:30 am - 5:30 pm
Friday
8:00 - 8:30 am 10:30am - 3:30pm
Saturday
By Appt. Closed
Sunday
Closed Closed