Online Forms

Pro-Active Wellness & Injury Centre offers our form(s) online so they can be completed 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.
  • Once printed and completed, you can email your forms to Dr.Bartosh@pro-activewellness.com.  You may also fax them to 217-213-5094, or bring it to your appointment.  

New Client Health History Form

*Also, please bring in any other health records, exams, blood tests, or x-rays you have pertaining to your current condition.

This lets 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

Informed Consent for Telemedicine Services

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

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Consent Agreement Concerning Scope of Practice, Laboratory Findings, and Nutritional Therapy

Pro-Active Wellness & Injury Centre of Danville, IL offers laboratory testing for the purpose of biochemical assessment of our patients. We also offer nutritional supplementation for the purpose of correcting biochemical imbalances.

Since nutritional deficiencies may or may not be associated with a specific disease, or it may be the cause of the disease, or it may occur as a result of that disease, it is important for you to fully understand that our sole concern in your case will be your nutritional program and your ability to absorb, metabolize and utilize the nutrients you consume. 

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New Client Nutritional / Metabolism Form

*Also, please bring with you any other health records, exams, blood tests, x-rays or other information you may have available pertaining to your current condition.

This information reveals how your body is responding and functioning in response to your environment and will help us to help you.

Download & Print Form

New Client Lung Profile

*Also, please bring with you any other health records, exams, blood tests, x-rays or other information you may have available pertaining to your current condition.

This information reveals how your body is responding and functioning in response to your environment and will help us to help 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 into 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!

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