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Health and Wellness Center of Mid America offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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 Forms

To be completed by all new patients – unless you are being seen for injuries resulting from an auto accident or that are work related. (See below for auto/work injury forms.)

Adult

Birth – 4 yrs old

Pediatrics


Returning Patient forms

Returning Patient Update Form


Auto Accident/Personal Injury

Basic Patient Information

Automobile and Accident Questionnaire

Application For Benefits


Worker’s Compensation Authorization

Approval of supervisor or Human Resources representative required for all work related injuries. Expediency and accuracy in the completion of this form will allow us to treat you in a more timely manner.



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