1019 West Galena Ave.
Freeport, IL 61032

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Current Symptoms

If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?

Personal Health History

Family/Primary Physician

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Worker's Compensation

Describe the accident?

Do you lift from?

Do you have to reach?
Is your work area cluttered?
Do you push or pull?
Do you pick up or lift?

Do you lift in and out of a machine?
Type of Floor:

Type of ventilation:

Type of lighting:

Is your work area:

Do you have any other jobs?
Has outside help been hired?
Do you use a cart?

Auto Accident

Visited a Hospital or Doctor?

Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:


Certification and Authorization:I certify that I'm the patient or legal guardian listed above. I have read/understand the included information and certify it to be true and accurate to the best of my knowledge. I consent to the collection and use of the above information to this office of chiropractic. I authorize this office and its staff to examine and treat my condition as the doctors see fit. I hereby authorize the doctor to release all information necessary to any insurance company, attorney, or adjuster for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. Authorization of Payment:I hereby guarantee full payment for all services rendered to me by Chiro-Works. I understand and agree that health insurance policies, accident insurance policies, personal injury claims, and any other third party pay arrangements are between the third party and me. I understand that Chiro-Works will assist me in preparing the necessary reports and forms to enable me to make collection from insurance companies and other third parties. I will authorize and direct third parties to make payments directly to Chiro-Works, said payments will be credited to my account upon receipt. I understand that all services rendered to me are my responsibility and I guarantee the payment thereof. I agree that my account shall be payable in full upon the completion (by settlement or trial) of any personal injury claim. I understand that fees for professional services will become immediately due upon suspension or termination of my care or treatment.In the event of a default under the terms of this Agreement, I understand that Chiro-Works may accelerate the full balance due for my treatment. In the event of a default, I agree to be responsible for any attorney’s fees and costs incurred by Chiro-Works to collect the balance due on my account. In the event of a default under the terms of this Agreement, I agree to pay 1.5% interest per month (18% per annum) on the unpaid balance. I understand that in the event I fail to make any payment as required by this Agreement that I will be in default. I authorize my attorney and any insurance company involved in my claim to make direct payment to Chiro-Works for payment on my account.

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:

Finalizing Form

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