New Patient Paperwork

Eickhorst Family Chiropractic offers our patient form(s) online so they can be completed in the convenience of your own home or office.

  • All forms are PDF files. You will need AdobeReader® to view them.
  • If you do not already have AdobeReader® installed on your computer,
    Click Here to download.
  • Download the necessary form(s), print them out and fill in the required information.
  • Bring the necessary form(s) to your appointment.

Adult history forms

pediatric history forms

auto accident & workers 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!

We are In-Network with Aetna!

Aetna Logo

We accept most insurances and are in-network with Blue Cross Blue Shield, and Medicare!

9:30am - 12:30pm
3:00pm - 6:00pm

9:30am - 12:30pm
3:00pm - 6:00pm

9:30am - 12:30pm
3:00pm - 6:00pm

9:00am - 1:00pm



Eickhorst Family Chiropractic
5190 Euclid Avenue
Palatine, IL 60067
(847) 202-0002
Fax (847) 202-0070