360 E Irving Park Road

Roselle, IL 60172 USA


Patient Forms

Please use the following links to print and fill out our insurance coverage and patient health history forms. The forms are in the PDF format; in order to view them you will need a PDF viewer such as Adobe Reader. If you do not have Adobe Reader you can click here to download it FREE.


New Patient/Update/Progress Form

Personnel Injury Packet

Work Injurym Packet

Update Re-Exam

Progress Evaluation

Patient Health Information Consent Form

Pediatric Form

Health History Form

Neck Questionnaire

Back Questionnaire

Arm Questionnaire

Lower Extremity Questionnaire

Functional Rating Index

Patient File Update

Testimonial and Photo Release Form

Discount Medical Plan Application

Informed Consent To Chiropractic Treatment

Consent To Examine And Treat Minor Child

Medicare Advance Beneficiary Notice of Non-coverage (ABN)

Verification of Insurance Benefits

Superbill Charge Form

Good Faith Estimates

Good Faith Estimates

Patient Email and Text Release

Informed Consent for Telemedicine

Medical Record Release

X-ray Release

Forms For Children With Sensory Concerns

Child Treatment Consent Form

Consent to Examine Minor Child

Pediatric Form

Infant/Toddler Sensory Academic Profile

Ages 3 – 4 Sensory Academic Profile

Ages 5 – 12 Sensory Academic Profile

Ages 12+ Sensory Academic Profile


Food Intake

Symptom Survey Form

Wellness Intake Forms

Wellness Chart

Testing and Nutritional Release


We attempt to take out as much of the “insurance hassle” as possible for you. We’ll happily telephone your insurance company to verify your coverage benefits. Please remember, however, that the benefits quoted to us by your insurance company are not a guarantee of payment. We will file your claim and await payment for 90 days. If your company pays the benefits they quote to us, the only services you will be responsible for are any non-covered services, deductibles or co-pays. If you have any questions at all regarding you financial responsibilities at our office, please do not hesitate to ask. Our insurance clerk has years of experience and will be happy to assist you.


An increasing number of patients do not have insurance, or have plans with limited coverage, such as catastrophic policies. We realize that no one wants to build up a large bill. Therefore, we have several plans so those patients may receive complete care without undue financial difficulty. Of course we are always happy to accept cash, your personal check, MasterCard, Visa or Discover cards.

“ON THE JOB” INJURY (Worker’s Compensation)

If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you suspend or terminate care, any fees and services are due immediately.


Please notify your auto insurance carrier of your visit to our office immediately. Notify our insurance department immediately if an attorney is representing you. Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due immediately.


We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that Medicare will cover, which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20% as well as any non-covered services. Our office completes and files the forms for Medicare at no charge.


Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.

Contact Us

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Office Hours

Find Out When We Are Open


8:30 am-1:00 pm

3:00 pm-7:00 pm


8:00 am-2:00 pm


8:30 am-1:00 pm

3:00 pm-7:00 pm




8:00 am-2:00 pm


8:00 am-12:00 pm