Florida Wellness & Rehab 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 Intake Form - Required

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!

Informed Consent Form - Required

This form enables Florida Wellness and Rehab to provide services to the patient.

HIPAA Information and Consent Form - Required

This form outlines your rights provided by the Health Insurance Portability and Accountability Act and addresses what Florida Wellness and Rehab can and cannot do with your information.

Assignment of Benefits Form - Required

This form allows Florida Wellness and Rehab to bill and collect directly from your insurance company.

New Cancellation Policy - Required

This form summaries the cancellation policy adopted by Florida Wellness & Rehab in 2009.

ChiroVoice Information Page - Optional

Lets us enroll you in the he chiropractic advocacy network, a dedicated group of supporters who educate policymakers about the value of chiropractic and work to positively impact any legislative efforts to reform the current national health care system. Through the chiropractic advocacy network, patients and chiropractic supporters can stay informed about important health care issues and contact their legislators in Washington.

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