Dr. Jack Li Chiropractic | West LA & Santa Monica Chiropractor
12340 Santa Monica Blvd Suite 129
West Los Angeles, CA 90025
Tel: 310-207-1007
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New Patient Forms

Please book an appointment online to fill out the Intake Form directly online. 

New Patient Initial Intake Form 
New Patient Intake Form
File Size: 1067 kb
File Type: pdf
Download File


New Patient with HMO or PPO insurance under American Specialty Health (ASHP), please use this form.
ASHP Initial Intake
File Size: 136 kb
File Type: pdf
Download File

For returning ASHP patient with new condition or last seen over 30 days ago, please complete this progress form prior to your visit
ASHP Progress Note
File Size: 1010 kb
File Type: pdf
Download File


New Patient Personal Injury/Motor Vehicle Accident Injury Form
Personal Injury Form
File Size: 358 kb
File Type: pdf
Download File

Location

Office Hours

Monday  9:30 AM - 7 PM 
Tuesday 9:30 AM - 2 PM
Wednesday 9:30 AM - 7 PM 
Thursday By Appointment
Saturday 9 AM -3 PM
Fri & Sun: Closed
Office Information

Dr. Jack Li, D.C.
12340 Santa Monica Blvd, Suite 129 
West Los Angeles, CA 90025

Call for an appointment

(310) 207-1007 
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