top of page

Welcome
Reviews
Insurance
Hours
Massage
Services
Orthotics
Contact
More

Use tab to navigate through the menu items.

Online Scheduling for Existing Patients

Workers Compensation Intake

First Name

Employer/ company at time of injury?

Last Name

Are you still employed at this company?

Date of Injury

BWC Claim Number:

Is there a managed care company ?

Name of MCO:

MCO Phone Number:

Have you retained an attorney?

Attorney Name:

Attorney Phone Number:

Have you missed work?

If yes, please list all dates

Job Description?

Were you transported to the emergency room?

Name of emergency room?

I confirm that the information given in this form is true

1038 South Washington St. Millersburg OH 44654
P: 330.674.4373 F:330.556.4086

bottom of page