New patients

Request a first visit

Leave your contact details and the times that suit you. We will be in touch within one business day to set a time and check your insurance.

Full name

Phone

Email (optional)

How should we reach you?

Call Text Email

When could you come in? Pick as many as work.

MorningMiddayLate day Mon Monday morning, 7:30–12 Monday midday, 12–3 Monday late day, 3–6 Tue Tuesday morning: Closed Tuesday midday, 12–3 Tuesday late day, 3–7 Wed Wednesday morning, 7:30–12 Wednesday midday, 12–3 Wednesday late day, 3–6 Thu Thursday morning: Closed Thursday midday, 12–3 Thursday late day, 3–7 Fri Friday morning, 7:30–12 Friday midday: ClosedFriday late day: Closed Sat Saturday morning, 8–11 Saturday midday: ClosedSaturday late day: Closed

Closed on Sundays. Each box shows the clock hours it covers.

Please leave health details out of this form. They go on the secure intake form we text you.

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After you send it

We reach out the way you pickedWithin one business day, by call, text or email, to settle a time.
We text you the intake formsHealth history goes there, on a secure form, not on this page.
We check your insuranceIf you are using it, we call your plan and tell you what you are likely to owe.

Bring with you

A photo ID
Your insurance card, if you are using it
A list of medications you take
Any X-ray or MRI reports you already have
Clothes you can move in

Rather talk to someone?

(616) 555-0137

The front desk answers whenever we are open, Monday to Saturday.

Upright Chiropractic Eastown · Grand Rapids

Dr. Nora Brink, D.C. and Dr. Jonah Pell, D.C. Doctors of Chiropractic, licensed in Michigan.

Visit

1638 Lake Drive SE, Suite 2
Grand Rapids, MI 49506

(616) 555-0137
frontdesk@uprightgr.example

Hours

Mon 7:30 am – 6 pm
Tue Noon – 7 pm
Wed 7:30 am – 6 pm
Thu Noon – 7 pm
Fri 7:30 am – noon
Sat 8 am – 11 am
Sun Closed

Pages

Your first visit Cost & insurance Request a visit

If you think you are having a medical emergency, call 911.