Online Forms

Back In Action Chiropractic offers our patient form(s) online so they can be completed 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 (262-884-7589) us your printed and completed forms or bring them with you to your appointment.

New Patient Information Form - Required

This gives us all of the pertinent information we need to get your account set up.  We will also need you to bring in your insurance card (if applicable) and photo identification to your appointment.  If you would like us to verify your insurance eligibility prior to your appointment, please fax a copy of your insurance card, along with the subscriber's name and date of birth if not you, and this form.  We will do our best to verify your coverage prior to your arrival.

Download & Print Form

HIPPA Forms - Required

These forms are required in order for us to send information to your insurance for billing purposes, call you with appointment reminders, and let you know about new products and services we might offer at Back-In-Action.  If you have any questions as you read through these forms, please don't hesitate to ask.

Download & Print Form

Informed Consent & Consent to Treat a Minor - Required

As their titles imply, these forms allow Dr. Bakken and his staff to treat you.  Feel free to wait and sign them after you have had a chance to ask any questions you have prior to treatment.  In most cases, only the first of these forms is needed.  If you are a minor, a parent (or legal guardian) must sign the second form to allow treatment.  We encourage parents to accompany minors, especially on the first visit.

Download & Print Form Informed Consent

Download & Print Form Consent to Treat a Minor

 Member Wellness Registration Form - Optional

This form can be filled out to register for access to the member wellness section of our website. You can also sign up for our monthly newsletter to keep up on current health issues and news and events in our office. You can print it out and bring it in to our office or Click Here to register online! The online newsletter sign-up is also on the right. We look forward to making your experience with our office and website more interactive and rewarding!