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Online Forms

Back To Health Chiropractic offers our patient forms online so you can complete them in the convenience of your own home or office.

  • Download the necessary form(s), print it out and fill in the required information.
  • EMAIL us your printed and completed form(s); FAX to 219-326-0180 OR BRING THEM with you to your appointment.

NEW PATIENT Forms (REQUIRED)

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 just let us know. This information will help us help you better! 

Click Title to Download & Print.

New Patient Forms for NON-MEDICARE- Required forms for ages 10-65.

New Patient Forms for MEDICARE- Required forms for ages 65 and older. 

New Patient Forms for PEDIATRIC - Required forms for ages 10 and younger. 

New Patient Forms for AUTO ACCIDENT- Required form packet if your care will be billed as a personal injury auto accident case.

New Patient Forms for WORKERS COMPENSATION- Required form packet if your care will be billed as a personal injury workers compensation case.

ADDITIONAL Forms

Patients Guide to Insurance Verification - We will be happy to verify your insurance coverage for you before you begin care; however, if you would like to take an active role in determining your insurance benefits prior to making an appointment, this form will be your guide. (Good luck! You'll need it dealing with the insurance company.)



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