Back To Health Wellness Center offers our patient forms online so you can complete 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) to 219-326-0180 or bring them with you to your appointment.

REQUIRED New Patient Forms

This let’s us know the history and current state of your health. Filling these out prior to your visit will help shorten your initial visit time if you so choose. Any questions or concerns jsut let us know! This information will help us help you better. CLICK TITLE to Download & Print.

Confidential Patient Case History (4 pages) - Required for all new patients over the age of 10.

Informed Consent (1 page) - Required for all patients regardless of age.

Appointment Policy, Financial Policy & HIPAA Notice (3 pages) - For your review prior to signing Confidential Patient Case History form.

Pediatric Health History (2 pages) - Required for all new patients under the age of 10.

OPTIONAL New Patient Forms

Patients Guide to Insurance Verification (1 page) -

Member Wellness Registration Form - 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!