Follow the steps to easily complete the online intake form.

1. Click ‘Get Form’ button to start the process and access the intake form.
2. Enter the patient’s name, age, and birth date in the designated fields. Ensure spelling is accurate to avoid any identification issues.
3. Fill in the patient’s address, including the city, state, and zip code.
4. Provide the names of parents or guardians, along with their home, work, and cell phone numbers. Enter an email address for communication.
5. Indicate how you were referred to this office by filling in the referred by section.
6. Decide whether you would like the office to verify your health insurance coverage by checking the appropriate option.
7. In the consultation section, explain the reason for seeking chiropractic care and any relevant details regarding the problem, including when it began and its frequency.
8. Indicate if the issue interferes with your child's sleep, eating, or daily routine, and specify additional information if necessary.
9. Provide prenatal history and details regarding any complications during pregnancy or delivery if applicable, including birth weight, length, and APGAR scores.
10. Complete the medication history by listing previous chiropractic visits and names of healthcare providers, along with any ongoing medications your child is taking.
11. Answer questions regarding falls, injuries, and past surgeries to give a comprehensive view of your child's health history.
12. Check all relevant childhood diseases and illnesses that your child has experienced.
13. Finally, sign the authorization to treat a minor section, affirming your consent for chiropractic care.
14. Once completed, make sure to save changes, download, or print a copy of the form for your records.

Complete your documents online today for efficient and effective chiropractic care!