Online Forms

Chiropractic Rehabilitation Wellness Center offers our patient form(s) online so you can complete it in the convenience of your own home or office.

  • If you do not already have AdobeReader® installed on your computer, Click Here to download.
  • Download the necessary form(s), print it out and fill in the required information.
  • Fax us your printed and completed form(s) or bring it with you to your appointment.


New Patient Health History Form - Required

This let’s us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download & Print Form


Download the Free AdobeReader®

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Exlcusive Offer

Patient Appreciation Day, Saturday, May 19th 2012 8:00 - 11:00

Patient Appreciation Day is our way of saying Thank You to our valued patients! We will be serving a delicious breakfast and our current patients will receive a *FREE adjustment on Saturday, May 19th from 8:00 – 11:00 am. Sign-up using the form or call us at 847-362-8882 to RSVP FOR BREAKFAST.
There’s more…Current patients who refer a new patient to our office will receive a FREE 30 minute massage. All new patients referred by you will receive the following AT NO CHARGE for the month of May: Consultation, Examination, Any necessary X-Rays and a Report of Findings (scheduled on a separate day) JUST HAVE YOUR FAMILY MEMBERS AND/OR FRIENDS MENTION THIS FLYER!

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