Online Forms

Naperville Rehab Clinic 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 AdobeReaderÃ�® 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.

Cash & Health Insurance Patients

Download & Print Form

Personal Injury Patient

Download & Print Form

Worker's Comp Patients

Download & Print Form

United Health Care Patients

Some UHC policies require authorization from OptumHealth, please fill out the OptumHealth Patient Summary Form along with other form(s) according to any/all pain you are experiencing.

OptimumHealth Patient Summary Form

Download & Print Form

A) Back Pain: Download & Print Form
B) Neck Pain: Download & Print Form
C) Upper Extremity Pain: Download & Print Form
D) Lower Extremity Pain: Download & Print Form

If you are not sure if your policy requires authorization, please contact our office.

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 office. You can print it out and bring it in to our office 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!