New Patient Paperwork

New Patient Paperwork

Here is our new patient paperwork. If you would like to complete the paperwork prior to your appointment, simply download the forms, print them out, and bring in the filled out paperwork to your appointment.

If you have any questions please feel free to contact us at 773-665-4400 or realignchiro@gmail.com

New Patients will have to fill out ALL of the following forms:

  • New Patient Intake Form- the first form for our office, this contains general information about you: who you are, how you found us, your insurance, reason for your visit, etc.
  • Visual Analog Scale- This is a visual pain scale. Mark where you are experiencing pain or discomfort and sign the bottom.
  • Neck Pain Index- Check the boxes that pertain to you.
  • Back Pain Index- Check the boxes that pertain to you.
  • Patient Financial Policy- This form explains our financial policy, appointment policy, and gives us the assignment of benefits which is giving us permission to bill you (or your insurance) for your visit to our office.
  • Patient Privacy Practices- This form explains our privacy practices.
  • Pregnancy Release Form- This form is for anyone who has the potential to become pregnant. We need you to attest that you are not pregnant in the event that we take x-rays. X-rays are not taken if you are pregnant. Please inform our staff if you are, or believe that you will be.

Locations

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Office Hours

Our Regular Schedule

Primary Location

Monday:

8:45 am-11:45 am

1:45 pm-6:00 pm

Tuesday:

12:45 pm-6:00 pm

Wednesday:

8:45 am-11:45 am

1:45 pm-6:00 pm

Thursday:

Closed

Friday:

8:45 am-11:45 am

1:45 pm-6:00 pm

Saturday:

8:45 am-1:00 pm

Sunday:

Closed