Active Chiropractic

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330.674.4373
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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

Thanks for submitting!

Chiropractic Hours

Monday 7:30 am - 7:30 pm

Tuesday 7:30 am - 5:30 pm

Wednesday 7:30 am - 7:30 pm

Thursday 7:30 am - 5:30 pm

Friday 7:30 am - 5:30 pm

Saturday 8 am - 11 am

Sunday Closed

Chiropractors

Dr Jeff Alexander

Dr Derek Reutter

1038 S Washington St Millersburg, OH 44654 Tel 330.674.4373 Fax 330.556.4086

serving: Millerburg, Wooster, Loudonville, Berlin, Sugarcreek, Coshocton