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In order to provide you the best possible wellness and chiropractic care, please fill out the form below. Please set aside about 20 minutes. Please fill out completely to avoid extra paperwork during your visit to our office.

Patient Information

Mailing Address and Contact Information

Insurance Information

*If an auto accident, please provide:


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.

3. Past Medical History

Have you ever:

Family History


Review of Symptoms

Symptoms and Areas of Complaint: Please only list one area at a time. (headache,neck,upper back, lower back, ribs, shoulder, hips, knees, ankles, feet)

Symptom 1

Symptom 2: Please scroll to bottom if no other symptoms.

Symptom 3: Please scroll to bottom if no other symptoms.

Any Additional Symptoms? Please list here any additional concerns you have, and we will be sure to cover them during your visit with the Doctor. Thank you!

Thank you for completing our online intake! We look forward to connecting with you soon!

New Patients Welcome

Sign up using the form below or call us at 503-287-2273 to make your appointment!

THIS ---->https://concordiachiropractic.chiromatrixbase.com/new-patient-center/new-patient-health-history-form.html

Office Hours

Day Open Closed
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9:00am 9:00am 9:00am 9:00am 9:00am 9:00am Closed
5:00pm 5:00pm 5:00pm 5:00pm 5:00pm 1:00pm Closed


I can now drive a car, take my child to numerous activities, successfully make it through a pregnancy with little or no discomfort - lead a normal life. I would highly recommend to anyone who lives with physical pain or disfunction to turn to Dr. Jason Lindekugel and the Postural Alignment Exercises. The decision will change your life.

Jephta Bernstein
Portland, OR

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