New Patient Forms

Naperville Rehab Clinic offers our patient forms online so they can be completed 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 forms from the list below that pertain to your visit, print them out and fill in the required information.
  • Bring them with you on your first appointment.
Cash & Health Insurance Patients
Personal Injury Patient
Workers’ Comp Patients
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. Don’t forget the forms above for Cash & Health insurance patients.

OptumHealth Patient Summary Form
C) Upper Extremity Pain:
D) Lower Extremity Pain:
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