Patient Forms
For all new patients: Please choose the section that applies to the patient.
Please download all the PDF forms in that section and fill them out PRIOR to your appointment with Dr. Breunig. Bring completed forms to your appointment.
You can either print the forms and fill them in manually or enter the information into the form fields within Adobe Acrobat Reader and then print them. Some of the forms only require signatures.
If needed, click here to download Adobe Acrobat for free.
Adult, Teen, or Child age 6 or older
Financial Information
Notice of Patient Privacy Policy
Consent to use Protected Health Information
Cancellation Policy
Registration Form
Patient Case History
Infant or Child age 5 or younger
Financial Information
Notice of Patient Privacy Policy
Consent to use Protected Health Information
Consent to Treatment of Minor Child
Cancellation Policy
Registration Form
Pediatric Case History
Motor vehicle accident injury
Financial Information
Notice of Patient Privacy Policy
Consent to use Protected Health Information
Cancellation Policy
Registration Form
Motor Vehicle Accident Intake
Work-related injury
"Whether we're working on an acute or chronic problem, I always feel like Dr. Breunig is patient with my process. She treats me with respect and great care, combined with effective methods. She's the best!!”
— VT, St. Paul