Chillicothe Chiropractic and Wellness Center, Inc. offers our patient form(s) online so they can be completed 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!

Personal Injury History Form - Optional

This form is required if your condition has arised from a motor vehicle accident or slip/fall injury.

Download & Print Form

 Authorization for Information Release - Optional

Use this form to request your protected health information such as diagnostic testing or consultation reports, to be sent to our doctors for review.

Download & Print Form

 Consent for Minor Treatment - Optional

This form is necessary for our office to treat any person under 18 years of age and must be signed by a parent or legal guardian.

Download & Print Form

Patient Report of Independent Medical Examinaiton (IME)

This report is completed by the patient following an Independent Medical Examination, frequently utilized in Worker's Compensation cases.  The report helps provide information about the examination and to help assure the accuracy and legitimacy of the conclusions drawn from the examination.

Download & Print Form

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!