Online Forms

Whole Health 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 us your printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form - Required

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

General:

Welcome Sheet (Front)

Welcome Sheet (Back)

Claim Form

Services Rendered Agreement

WHC Notice of Privacy Practices

Authorization, Assignment & Release Form

If you are a United Healthcare patient, then you will need to fill out these forms as well as the general:

United Healthcare Forms

If you are a personal injury patient, then you will need to fill out these forms as well as the general:

Personal Injury Patients

Vehicle Accident Information (Front)

Vehicle Accident Information (Back)

Insurance Information for PI Patients

Instructions to Counsel

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!