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847-885-8820 H
H

847-885-8820

New Patient Health History Form

In order to provide you the best possible wellness care, please complete this form

Patient Data

Mailing Address

Current Complaints

Nature of Injury

Insurance Information

*If an auto accident, please provide:

Signatures

Name of the Insured _____________________________________________

I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.

Patient's signature _______________________________________________

Date ____________________

Spouse's or guardian's signature __________________________________

Date ____________________

Medical History

Have you ever:

Family History

Habits

Have you ever suffered from:

Exclusive Offer

We specialize in OWCP/ DOL federal work comp injury cases.

Sign-up using the form or call us at 847-885-8820 to take advantage of this exclusive offer

Office Hours

DayMorningAfternoon
Monday8:00am - 1pm2:30pm - 5:30pm
Tuesday9am - 1pm2:30pm - 6:30pm
Wednesday8:00am - 1pm2:30pm - 5:30pm
Thursday9am - 1pm2:30pm - 6:30pm
FridayClosedClosed
SaturdayClosedClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:00am - 1pm 9am - 1pm 8:00am - 1pm 9am - 1pm Closed Closed Closed
2:30pm - 5:30pm 2:30pm - 6:30pm 2:30pm - 5:30pm 2:30pm - 6:30pm Closed Closed Closed