Patient Forms - Freeport Family Chiropractic

Freeport Family Chiropractic & Acupuncture 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 completed form(s) or bring them with you to your appointment.
    Our fax is (815) 233-3379


New Patient Health History / HIPPA / Insurance Forms – Required


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!

SHAPE ReClaimed Program Form

SHAPE ReClaimed Intake