As Roger’s most innovative health and wellness clinic, our goal is to facilitate easy and convenient access to naturally-based, drug-free upper and lower back pain relief and rehabilitation services. In an effort to streamline our patient check-in process, we’ve compiled our patient intake forms and required paperwork, making it convenient for you while saving time at your physiotherapy appointment. Please fill out all pertinent information before your scheduled physiotherapy appointment time. If you should have any questions regarding any of the information or your health insurance coverage, please don’t hesitate to call our offices.

Welcome to DMR Clinic Rogers, we look forward to a happy and healthy relationship with you and your family.

Click on the links below to download our new patient forms.

Fill out these forms at home before you come for your first visit!


DMR Paperwork

  • Chiropractic Intake Forms
  • Physical Therapy Intake Forms
  • Oswestry Disability Index
  • DMR Referral Form
  • Financial Policy
  • Auto Accident Questionnaire
  • Consent to Treat a Minor



Being well-prepared for your physiotherapy appointment will ensure that the providers have all of the needed information to provide the best possible care for you. It also will help relieve any unnecessary anxiety you may be feeling about our sciatica treatment or other upper/lower back pain relief treatment. Please bring with you to your consultation or first appointment your most recent MRI report or X-ray images, if available. We will also need a copy of your ID and insurance so we can call for your benefits at our clinic. After checking in and filling out new patient paperwork, you’ll meet with a chiropractor to review your case and develop a upper/lower back pain relief treatment plan.