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630-378-4100

Sign up using the form below or
call 630-378-4100.

Geipel Chiropractic offers our patient forms online so they can be completed in the convenience of your own home or office, before you even arrive to our chiropractic 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.

Application for Treatment

Used for physical conditions such as back pain, neck pain, extremity pain, headaches, etc. Basic form for chiropractic conditions. Please fill out completely. Please list the most current date your condition began in the second question under symptoms. For instance: what day caused you to have enough discomfort to call for an appointment, when was the most recent date which you experienced your symptoms.

Download & Print Form
 

Update Reactivate under 1 year

Used for patients who have not been in our office for one month but not more that 1 year. Used for physical conditions such as back pain, neck pain, extremity pain, headaches, etc. Basic form for previous patients not seen within one month but less than 1 year. Please fill out completely. Please list the most current date your condition began. For instance: what day caused you to have enough discomfort to call for an appointment, when was the most recent date which you experienced your symptoms.

Download & Print Form
 

Symptom Survey (Nutritec Symptom Survey)

Used for all patients for nutritional evaluations. Also given prior to Acoustic Cardio Graph (ACG) readings to coincide with the readings from ACG. Please fill out top information completely excluding blood pressure readings, pH reading, and pulse. Only answer the areas which apply to you. If the symptom is something you DO NOT EXPERIENCE, please leave blank. For mild symptoms such as experiencing the symptom once or twice in the last 6 months mark the first circle. Moderate symptoms are symptoms which you experience once or twice in the last month. Severe symptoms are symptoms which are chronic and you experience them once or twice in a week. If unsure about a symptom because you avoid things to keep you from experiencing it then this is a severe symptom. For example, if you avoid a certain food because you know it will upset your stomach then you will mark it as a severe symptom. You may fax this form to our office at (630) 378-9963 prior to your appointment. Please make sure name is on all sheets being faxed and circles are marked clearly. (Using a black permanent marker on this form when faxing works well.)

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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 chiropractic office. You can print the form out and bring it in to our office during your next visit with our chiropractor, 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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Patient Health History

In order to provide you with holistic care and address the root cause of your health concerns, we would like you to complete a detailed and comprehensive health questionnaire.  Your answers will help you achieve better treatment results.  The more you are willing to share with us, the better we can treat the root cause of your health conditions and symptoms.

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Office Hours

DayMorningAfternoon
Monday8:30am - 12pm2:00pm - 6pm
TuesdayClosedClosed
Wednesday8:30am - 12pm2:30pm - 6pm
Thursday8:30am - 12pmClosed
Friday8:30am - 12pm2:00pm - 6pm
Saturday8:30am - 12pmClosed
SundayClosedClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
8:30am - 12pm Closed 8:30am - 12pm 8:30am - 12pm 8:30am - 12pm 8:30am - 12pm Closed
2:00pm - 6pm Closed 2:30pm - 6pm Closed 2:00pm - 6pm Closed Closed