If you need a more accessible version of this website, click this button on the right. Switch to Accessible Site

WARNING

You are using an outdated browser. Please upgrade your browser to improve your experience.

Close [x]

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:

$47 New Patient Consultation

Sign-up using the form or call us at 937-236-0464 to take advantage of this exclusive offer.

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

Office Hours

DayMorningAfternoon
Monday7:30am-9am 10-11am3:30-6pm
Tuesday9-11am 12-12:30 pm3:30-5pm
Wednesday7:30-9am 10-11am3:30-6pm
ThursdayClosed3:30-5pm
Friday7:30am-9am 10-11pm3:30-6pm
SaturdayBy Appointment Only 9am-9:30amClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:30am-9am 10-11am 9-11am 12-12:30 pm 7:30-9am 10-11am Closed 7:30am-9am 10-11pm By Appointment Only 9am-9:30am Closed
3:30-6pm 3:30-5pm 3:30-6pm 3:30-5pm 3:30-6pm Closed Closed

Testimonials

Dear Dr. Peltier,
When I first came to see Dr. Peltier, I was having pain in my neck, lower back and hip sockets. I could hardly walk and it was difficult to stand for very long. So getting daily chores done was very painful. I saw improvement as the program progressed. I began a walking program in April of 09, and now I walk daily. I feel better than I have in years. I can get things done without pain, am stronger and have better balance. I highly recommend the program, it works.

Sandi W.
Huber Heights, OH

Newsletter Sign Up