Banner

Welcome to Go Chiro Mobile! This secure form collects your health history, current concerns, and care goals. Please complete it before your first visit to help us prepare personalized care.

New Patient Intake Form

Let the power of chiropractic light your way to health

Embed

<!DOCTYPE html>
<html lang="en">
<head>
  <meta charset="UTF-8" />
  <meta name="viewport" content="width=device-width, initial-scale=1.0" />
  <title>Schedule Your Visit</title>
  <style>
    body { font-family: Arial, sans-serif; max-width: 700px; margin: auto; padding: 20px; line-height: 1.6; }
    .question { margin-bottom: 20px; }
    .hidden { display: none; }
    button { padding: 10px 20px; margin-right: 10px; margin-top: 10px; cursor: pointer; }
    #final-link { margin-top: 30px; font-weight: bold; }
  </style>
</head>
<body>
  <h1>Let's Get You Scheduled</h1>
  <div id="step1" class="question">
    <p>Are you a new or returning patient?</p>
    <button onclick="nextStep('new')">New</button>
    <button onclick="nextStep('returning')">Returning</button>
  </div>

  <div id="step2" class="question hidden">
    <p>Please enter your ZIP code:</p>
    <input type="text" id="zip" maxlength="5" />
    <br><br>
    <button onclick="checkZip()">Next</button>
  </div>

  <div id="step3-new" class="question hidden">
    <p>Do any of the following apply to your main concern? (Answer YES if any apply)</p>
    <ul>
      <li>You have more than one area of complaint</li>
      <li>It has lasted more than 3 weeks</li>
      <li>Pain is greater than 4 out of 10</li>
      <li>The pain radiates to your arms or legs</li>
      <li>It started with an injury or accident</li>
      <li>You have a complex medical history or neurological condition</li>
    </ul>
    <button onclick="routeUser('new','focused')">No</button>
    <button onclick="routeUser('new','extended')">Yes</button>
  </div>

  <div id="step3-returning" class="question hidden">
    <p>Is this visit for your usual care with no major changes?</p>
    <button onclick="routeUser('returning','focused')">Yes</button>
    <button onclick="routeUser('returning','extended')">No</button>
  </div>

  <div id="final-link" class="hidden">
    <p>Click below to schedule your appointment:</p>
    <a id="booking-link" href="#" target="_blank"></a>
  </div>

  <script>
    let patientType = '';
    let region = '';

    const region1Zips = ["19013","19014","19015","19017","19060","19061","19703","19810"];
    const region2Zips = ["19022","19029","19033","19036","19043","19070","19074","19076","19078","19081","19086","19094"];

    function nextStep(type) {
      patientType = type;
      document.getElementById('step1').classList.add('hidden');
      document.getElementById('step2').classList.remove('hidden');
    }

    function checkZip() {
      const zip = document.getElementById('zip').value;
      if (region1Zips.includes(zip)) {
        region = 'r1';
      } else if (region2Zips.includes(zip)) {
        region = 'r2';
      } else {
        window.location.href = 'https://app.durable.co/website/builder?origin=login';
        return;
      }

      document.getElementById('step2').classList.add('hidden');
      document.getElementById(`step3-${patientType}`).classList.remove('hidden');
    }

    function routeUser(type, complexity) {
      const links = {
        r1: {
          new: {
            focused: 'https://gochiromobile.com/new-patient-visit-region-1-focused',
            extended: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=67ffebc06c5ae1618ae251e3'
          },
          returning: {
            focused: 'https://gochiromobile.com/return-visit-focused-1',
            extended: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=67fffd19b13412a0275f9b93'
          }
        },
        r2: {
          new: {
            focused: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=68000c0b966b0d649a2cb6b0',
            extended: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=67fff8186c5ae1618ae327ff'
          },
          returning: {
            focused: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=67fffc53b13412a0275f8aa2',
            extended: 'https://my.practicebetter.io/#/67f4a2170e49d232261b2ce3/bookings?r=67fffda2b13412a0275fa082'
          }
        }
      };

      const finalUrl = links[region][type][complexity];
      document.getElementById(`step3-${type}`).classList.add('hidden');
      document.getElementById('final-link').classList.remove('hidden');
      const link = document.getElementById('booking-link');
      link.href = finalUrl;
      link.innerText = 'Click here to book your appointment';
    }
  </script>
</body>
</html>