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New Patient Forms

At Modern Chiropractic Chicago, we offer our paperwork online so you can complete it in the convenience of your own home. Please download, print, and fill out to bring with you to your first appointment with Dr. Backhaus.

  • New chiropractic, acupuncture or physical therapy patients, please fill out the New Patient Intake, Informed Consent, Financial Policy and HIPPA forms.
  • New cosmetic acupuncture patients, please fill out the Financial Policy, HIPPA, Cosmetic Acupuncture Intake and Cosmetic Acupuncture Informed Consent form.

Man filling out paperwork

New Patient Intake

Informed Consent

Financial Policy

HIPPA

Cosmetic Acupuncture Intake

Cosmetic Acupuncture Consent

Modern Chiropractic Chicago Forms | (312) 208-1550