Get Co Lighthouse Chiropractic Pediatric Patient Intake Form 2022-2025

Filling out the CO Lighthouse Chiropractic Pediatric Patient Intake Form online is a straightforward process designed to ensure that all necessary information is collected for your child's chiropractic care. This guide will lead you through each section of the form to help you complete it efficiently.

Follow the steps to fill out the form online correctly.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the patient’s full name in the 'Patient Name' field, followed by their age and birth date in the respective sections. Make sure to keep the information accurate for the healthcare provider.
3. Provide the home address, including street, city, state, and zip code. This information helps in proper identification and correspondence.
4. Fill in the names of parents or guardians and their primary contact numbers. This is crucial for communication purposes.
5. Enter the email address for further communications and any information the clinic might need to send.
6. In the 'Referred By' section, indicate how you learned about the practice, which could be through a referral or other means.
7. Respond to the health insurance verification question by selecting 'Yes' or 'No', depending on your preference for the office to verify your coverage.
8. In the consultation section, provide details regarding the reason for seeking chiropractic care, including when the problem began, how frequently it occurs, and factors that alleviate or worsen the condition.
9. For prenatal history applicable to infants, include the name of the obstetrician or midwife, any complications during pregnancy, and birth intervention details.
10. Continuing with medication history, note any previous chiropractic visits, the names of pediatricians, and the child's immunization history.
11. Document any falls, injuries, or significant traumas the child has experienced, including the dates and types of sports played.
12. In the childhood diseases and illness section, check any applicable conditions. This helps in understanding the child's health background.
13. Finally, authorize treatment by providing your signature in the relevant section along with the date. This confirms your consent for care.
14. Once all fields are completed, you can save your changes, download the form for your records, print it out, or share it as needed.

Complete your CO Lighthouse Chiropractic Pediatric Patient Intake Form online today for a smooth and efficient onboarding experience.