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847-202-0002
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EXCLUSIVE OFFER: NEW PATIENTS RECEIVE A FREE CONSULTATION

For more information or to make an appointment, use this form below or call 847-202-0002.

Eickhorst Family Chiropractic offers our patient form(s) online so you can complete 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.

Adult History Forms

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Pediatric History Forms

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Auto Accident & Worker's Comp

Please complete this form if your symptoms are due to an auto accident and there is an auto insurance carrier claim. This let's us know the history and current state of your health. What questions, concerns, goals, regarding wellness can we help you with? Let us know!

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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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Featured Services

Services
We strive to provide complete care for our patients. Learn more about all the services we provide.
Make An Appointment
We will do our best to accommodate your busy schedule. Schedule an appointment today!
Online Forms
Our patient forms are available online so they can be completed in the convenience of your own home or office.