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4508 S. 4th St.
Leavenworth, KS 66048

(913) 250-6177

Reynolds Chiropractic offers Online Patient Intake Forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Unfortunately, the forms can only be filled out using one of these three browsers, Google Chrome, Safari or Firefox.  (Hopefully this option will be expanded in the near future to Internet Explorer.)You will be able to go to the link required and that will take you to the necessary forms you will need.
  • When you call to make an appointment, we will get your name, birthday and email. We will send you the link via your email and  you will also receive a link to download Google Chrome if you would like.  
  • Required forms are 1) Patient information, 2) Patient Sign-in, 3) Medical History.  
  • The forms can be long and tedious.  They are VERY THOROUGH!!
  • When you click done Your completed forms will be able to be reviewed by Dr. Reynolds before you arrive at your first appointment.
  • Good Luck with all this high tech stuff! : )  Give us a call during our office hours if you need assistance!


Medical History Form - Required

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Patient Sign-In - Required

This is where you will place a red dot on your biggest problem area first and answer all the questions in the box.  This you will place another dot in your next problem area and answer the questions for that specific complaint as well.  You can add as many dots as you would like, but you can also add more later.  We really need to know about your top 2 or 3 complaints.

Patient Information - Required

This is just your general information 

Insurance - Not required,  

but would be nice.  We can fill this in for you when we make a copy of your insurance card. 

Accident - Required if you were in an accident

This is a long form as well 



Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!

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