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Chiropractic and Progressive Wellness

partnered with

Danville Holistic Medical Center

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Online Forms

HealthSource offers our patient forms online so they can be completed it 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.

 

Required Forms

New Patient Health History Form

This lets us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

Download and Print Form Here

Entrance Application

Download and Print Form Here

HIPAA Declaration

Download and Print Form Here

Terms of Acceptance 

This form explains what our doctors do in our office.  Please read through and if you agree, print and sign your name and date the bottom of the page.

 The Alderman Analyzer 

We treat a variety of patients in our office.  Because each patient communicates differently, we have new patients fill out this personality profile so that we may better communicate with your personality style.

Download and Print Form Here


 X-Ray Agreement and Insurance Information

The front of this form explains that if our doctors deem that x-rays are clinically necessary, they will send them off to be read at no extra charge to you.  Please print your name, sign and date the bottom of this page.

Page 2 asks for more personal information.  It’s important that we have the correct insurance information, including Group ID, member ID, and the correct phone numbers.  Filling this form out will help us to more accurately determine your insurance benefits as related to chiropractic.

Download and Print Form Here