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Forms

Please print and complete these forms for your first visit. 

You are also able to arrive 15 minutes before your session to complete the paperwork in our office.

Patient Information

Credit Card

Telehealth Consent

Authorization and Consent

Symptom Questionnaire

Pediatric Bowel & Bladder

Insurance Information

Privacy Policy

Inside the Robert Kendal Salon

12319 S Harlem Ave

Palos Heights, IL 60463

back2healththerapy.com

Tel:  708.512.5124

Fax: 708.778.3204

email: backtohealth.contact@gmail.com

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