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Patient Forms

Draeger Chiropractic & Laser Center offers our patient forms online so that you can save time at your visit by completing them before you even arrive at our chiropractic office.

  • If you do not already have AdobeReader® on your computer, download it now.
  • Download form(s), print, fill in, and bring them along to your appointment.

1)  New Patient Health History Form - Required

This outlines the history and current state of your health. We also encourage you to write down any questions that you have, so that we can be sure to cover them during your appointment. Choose the appropriate form based on the patient's age.

Adults & Children over the age of 6
Children 6 years and younger

2)  Patient Reactivation - Required

If you are a returning patient, but haven't been to our office within the past 3 months, we will need to collect more recent health information. Please choose the appropriate form based on how long it's been since your last visit (if you're unsure, please don't hesitate to call us at 715-355-4224).

Your last visit was between 3 months and 1 year ago
Your last visit was more than 1 year ago

3)  Insurance Benefits Worksheet - Recommended

This worksheet helps you to understand your insurance coverage by outlining the questions you should ask your insurance provider. It is important to know that it is your responsibility to verify your coverage and understand your financial share of the services we provide. We strongly recommend that you bring this completed form with you to your first appointment. Download & Print Form.

4)  Medical Records Request

To transfer medical records between our office and another provider.  Download & Print Form

5)  Workers' Compensation

If your visit to our office was because of an injury that happened at work, please use this form. It is required for all Workers' Compensation claims. Download & Print Form

6)  Auto Accident History

Download & Print Form

7) Personal Injury Supplement

Our staff will let you know if this form is required as a supplement to Form #1 (Patient Health History).

Download & Print Form

8)  Nutrition Forms

If you are a Nutrition or Functional Medicine patient, the doctor may ask you to complete one or more of these forms:

Food Diary
Nutrition Questionnaire (Female)
Nutrition Questionnaire (Male)

9)  Member Wellness Registration Form

We invite you to access the member wellness section of our website and to subscribe to our monthly e-newsletter. You can register online or download & print the form and bring it with you to your next visit.