New Patient Forms

Harper Wellness & Rehab Center 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 (except United Healthcare or Great West Patients - see below required forms)

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!

Required for United Healthcare or Great West Insurance New Patient Health History Form 

Download & Print Form 

Auto Accidents Form - Required if this problem is a result of a recent auto accident

Download & Print Form

Medical Records/X-Ray Release Authorization

To release Medical Records/X-rays from a practitioner's office to Harper Wellness and Rehab, download and fax completed form to practitioner's office.

Download & Print Form

To release Medical Records/X-Rays from Harper Wellness and Rehab to a practitioner's office, download and fax completed form to Harper Wellness and Rehab.

Download & Print Form

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!