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815-485-8200

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Office Hours

DayMorningAfternoon
Monday7:00 AM1:00 PM
Tuesday1:00 PM6:30 PM
WednesdayClosedClosed
Thursday1:00 PM6:30 PM
Friday7:00AM1:00 PM
Saturday7:00 AM11:30 PM
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
7:00 AM 1:00 PM Closed 1:00 PM 7:00AM 7:00 AM Closed
1:00 PM 6:30 PM Closed 6:30 PM 1:00 PM 11:30 PM Closed

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