Online Forms

The FAIRLESS HILLS HEALTH CENTER offers our patient form(s) online so you can complete it in the convenience and comfort 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 Case History Form - Required

This let’s us know the history and current state of your health. It is required for all new patients, unless you were involved in an automobile accident or a work injury. If that is the case, you would need to fill out one of the forms below.

Download & Print Form

Personal Injury Questionnaire - Required if you were injured in an automobile accident

This let’s us know the history and current state of your health. It contains all of the detailed information we will need regarding your specific automobile injury.

Download & Print Form

Work Comp History - Required if you were injured at work

This let’s us know the history and current state of your health. It contains all of the detailed information we will need regarding your specific work injury.

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!