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Practice Name

Back to Balance Chiropractic and Wellness

Primary Location
2739 S 5600 W #170
West Valley City, UT 84120
Phone: (801) 966-5106

Office Hours

DayMorningAfternoon
Monday9:00 am6:00 pm
TuesdayClosed
Wednesday9:00 am7:00 pm
ThursdayClosed
Friday9:00 am6:00 pm
Saturday10:00 am2:00 pm
SundayClosed
Main Content

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

New patients receive a Complimentary Consultation.

Sign-up using the form or call us at (801) 966-5106 to take advantage of this exclusive offer.

Name: *
Email: *
Phone: *

Online Forms

Pain is not normal but common. Start today by scheduling an appointment and filling out your intake form to get out of pain.

Fill Out Intake Form

Testimonials

I love going to this office. I feel relaxed, and Dr. Roberts listens to what is going on, so he can better help you. Just referred my dad, and he was amazed. The staff is even amazing as well.

- Emily G. / West Valley City, UT

Office Hours

DayMorningAfternoon
Monday9:00 am6:00 pm
TuesdayClosed
Wednesday9:00 am7:00 pm
ThursdayClosed
Friday9:00 am6:00 pm
Saturday10:00 am2:00 pm
SundayClosed


Voted 2015’s best Chiropractor in West Valley City
for Chiropractic treatment
and services as reviewed by patients.
Verified by
Opencare.com

Contact

Back to Balance Chiropractic and Wellness
2739 S 5600 W #170
West Valley City, UT 84120
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