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Online Forms

Bettendorf Chiropractic Wellness Center offers our patient form(s) online so they can be completed it 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 printed and completed form(s) or bring it with you to your appointment.

New Patient Health History Form

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!

Download & Print Form


Minor Child New Patient Health History Form

Download & Print Form

Pediatric New Patient Health History Form

Download & Print Form


Download the Free AdobeReader®