- We strive to provide complete care for our patients. Learn more about all the services we provide.
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.
- Fax (262-884-7589) us your printed and completed forms or bring them with you to your appointment.
New Patient Information Form
Please bring 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 us a copy of your insurance card along with the following new patient information forms. We will do our best to verify your coverage prior to your arrival. If you are a minor, a parent or legal guardian must accompany you to your first appointment.
Download & Print New Patient Forms (Required)
Worker's Compensation Insurance Verification Download & Print Form (if applies)
Personal Injury Insurance Verification Download & Print Form (if applies)
These forms are required by the Health Information Patient Protection Act. If you have any questions as you read through these forms, please don't hesitate to ask.
Full Notice of Privacy Practices Download & Print Form (For your information)
Signature Page (included in New Patient Information above)