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Patient Information

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Preferred method of contact

Emergency Contact Information:

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Physician Care Information:

Have you seen a medical doctor within the last six months?

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Complete this section if injury was job related or motor vehicle accident

Is this accident related?

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Date of Injury:

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Do you have a caseworker?

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Do you have a attorney?

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SCHEDULE AN APPOINTMENT - CALL ONE OF OUR LOCATIONS TODAY

EAU CLAIRE Located in the Putnam Heights Shopping Center

517 East Clairemont Ave. | Eau Claire, WI 54701
Phone: 715.855.0408 | Fax: 715.855.0409
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    • Eau Claire Hours:
    Monday - 7:00 to 5:00
    Tuesday - 8:00 to 6:00
    Wednesday - 7:00 to 5:00
    Thursday - 8:00 to 6:00
    Friday - 7:00 to 5:00

  • GET DIRECTIONS get directions
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MENOMONIE Located across from Culvers

1309 Stout Road | Menomonie, WI 54751
Phone: 715.233.6230 | Fax: 715.233.6231
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    • Menomonie Hours:
    Monday - 8:00 to 5:00
    Tuesday - 7:00 to 6:00
    Wednesday - 8:00 to 5:00
    Thursday - 8:00 to 6:00
    Friday - 7:00 to 5:00

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RICE LAKE

1507 W. Knapp St., Suite #1 | Rice Lake, WI 54868
Phone: 715.236.3610 | Fax: 715.236.3615 Take a Tour
BARRON

1151 E. Division Avenue, Unit B | Barron, WI 54812
Phone: 715.637.3610 | Fax: 715.537.4610