therapy

Online Forms

Rockford Chiropractic Clinic offers our patient form(s) to be filled out online or downloaded so they can be completed in the convenience of your own home or office.  The forms are for Chiropractic and Massage Patients only.  (THESE FORMS ARE NOT NECCESSARY FOR DOT EXAMS.)

  • Click one of the links below to go to site for the online version that best suits your situation

Online Intake Form Instructions:

  • Simply follow the instructions all the way to the end.
    • Easy and fast!  If able, this is my preferred option.
      • the information is loaded right into your file for my review or created if not
    • Please Note:
      • You will get an email with a password that is needed to open the intake
      • You do have the option to print out the forms and fill out by hand 
        • this is found after gaining access to the intake form
        • upper right hand tab "fill this out by hand"

Intake Forms

Patient Online Intake Form links to fill out online: (please note type of insurance you have to pick appropriate link) 

INSURANCE:

INSURANCE INTAKE (all insurance other than Auto/Work Comp/Medicare/ or Medicade)

MEDICARE INTAKE (anyone retired or on Medicare)

MEDICADE / STATE INSURANCE

AUTO / WORK COMP INSURANCE

UPDATE INTAKE (if it has been awhile)


NON-INSURANCE:

CHIROPRACTIC TOS CARE - NO INS

MASSAGE THERAPY INTAKE

OTHER:

INSURANCE INFO / CARD UPLOAD


Download the Free Adobe ReaderĀ®

therapy

Newsletter Sign Up!

Get monthly advise and information about various Chiropractic Conditions that we treat.

Location

Find us on the map

Business Hours

Chiropractic Schedule

Monday:

9:00 am-6:00 pm

Tuesday:

9:00 am-4:00 pm

Wednesday:

9:00 am-6:00 pm

Thursday:

2:30 pm-6:00 pm

Friday:

9:00 am-4:00 pm

Saturday:

Closed

Sunday:

Closed