Beistline Chiropractic Family Wellness Center offers our patient form(s) online so they can be completed 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) or bring it with you to your appointment.
New Patient Health History Form - Required
This lets us know the history and current state of your health. What questions, concerns, and goals regarding wellness can we help you with? Let us know!
New Patient Information Form - REQUIRED
UnitedHealthcare Forms - Required for most UHC plans
UnitedHealthcare requires most patients to fill out additional paperwork in order to be eligible for coverage.
Patient Health Questionnaire (PHQ) - Fill out ONLY if you have UnitedHealthcare or PHCS Insurance
Neck Index - Fill out if experiencing neck pain
Back Index - Fill out if experiencing back pain
DASH - Fill out if experiencing pain in upper extremities
LEFS - Fill out if experiencing pain in lower extremities
Questions? Give us a call! (937)864-1404
Member Wellness Registration Form - Optional
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!
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Your health is your most valuable asset! Find out how we can help you get healthy and stay healthy. Call today for a FREE, no obligation consultation with sEMG.
(937)864-1404