Online Forms

FORD WELLNESS & REHAB offers our patient form(s) online so you can complete 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 - Required

This let’s 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

New Patient Peripheral Neuropathy Form - Required for PN Patients

If you are seeing Dr. Ford for peripheral Neuropathy, please fill out the questionnaire below. It helps us guage the extent of your Peripheral Neuropathy pain.

Download & Print Form

Auto Accident Questionnaire

If you are being seen for an auto injury, please fill out the Auo-Accident Questionnaire. Also, you will need to bring your auto insurance information, along with a claim number for your medical case, and attorney information if you have retained one. If you would like an attorney and have not retained one yet, we can refer you!

Download & Print Form

Worker's Compensation Questionnaire - Required for Worker's Comp cases

If you are a new or existing patient filing a worker's comp case, please fill out the form below. Also, you will need to bring your Worker's Compensation Insurance information along with the adjuster's name and claim number. If you have retained an Attorney, please bring that information as well. If you would like to retain an attorney, we can refer you.

Download & Print Form

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!