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Registration Form

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Please complete the online registration form, which includes Demographics, Referral information, Health History, and HIPAA/Emergency Contacts.  The forms may take 5-10 minutes to complete.   You can read the company’s Privacy Policy here.

Registration Form 11.1.23
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Any patient under the age of 18 must be accompanied by a parent or appointed guardian for ALL appointments.
Sex assigned at birth: *
Gender Identity:
Preferred Pronoun
Preferred method for appointment reminders: *
Can the office communicate via text? *
Billing Statements *

Parent/Guardian #1

Parent/Guardian #2

In The Event The Parent/Guardian Is Not Present

Referral, Provider, and Pharmacy Information

How did you hear about us? *

For statistical purposes only as required by the State of Wisconsin

Race *
Ethnicity *
Preferred Language *
Check if you would prefer appointment reminders via text/voice in Spanish

HIPAA and Emergency Contacts

Patient Authorization for use and disclosure of Protected Health Information (PHI) from the practice. Our office may contact you with appointment, billing and protected health information (PHI) through home, cell, or work number provided, and with your HIPAA approved contacts. It is your responsibility to inform the company of any changes. Please list contacts and check the box if they are HIPAA approved to receive PHI. One contact is required for Emergency use.
HIPAA Authorized Contact *
HIPAA Authorized Contact
HIPAA Authorized Contact
HIPAA Authorized Contact
As part of the 21st Century Cures Act, the practice is enrolled in Carequality/Commonwell health information exchange. Upon query, authorized staff has access to necessary electronic health information. If you wish to opt out, please check the box and your records cannot be queried.
I acknowledge that a copy of the Notice of Privacy Practices have been made available to me from Hand to Shoulder Center of Wisconsin and Woodland Surgery Center. Privacy Policy located in the link.
Patient/Representative Signature for Privacy Policy/HIPAA/Emergency Contacts
Patient/Representative Signature for Privacy Policy/HIPAA/Emergency Contacts
First name Digital Signature
Last name Digital Signature

Directions to Appleton Clinic (2323 N. Casaloma Drive)

Directions to Chilton Satellite Office (located inside Chaussee Chiropractic, 638 N. Madison Street)

Directions to Green Bay Satellite Office (1551 Park Place, Suite 100)

Directions to Marinette Satellite Office (2724 Cahill Road)