Intake Form

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Personal Information

Your Name

Date of Birth

What is the purpose of your appointment?

Marital Status

Your Email

Your Phone

Your Occupation Title

Your Employer

Name of Primary Physician or Chiropractor

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us?

sugar? currently and

Health Details

TERMS & AGREEMENT

A CHARGE WILL BE MADE FOR BROKEN APPOINTMENTS UNLESS 24 HRS NOTICE IS GIVEN.

By agreeing below, you confirm the following:

I have completed this form to the best of my ability and knowledge and agree to inform the technician of any changes in
the above information. I have been informed of and understand the contraindications to the requested treatments and
agree that I do not have any condition(s) that would make the requested treatment unsuitable. I will inform the
technician of any discomfort I may experience at any time during my treatment to allow them to adjust accordingly. I
agree to waive al/ liabilities toward my technician and the employer for any injury or damages incurred due to any
misrepresentation of my health history.

I Agree

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Chiropractic • Massage • Skin Care

Intake Form

CONFIDENTIAL INTAKE FORM

Personal Information

Health Details

Health Conditions / Treatments

On a regular basis, do you have difficulty with any of the following?

Esthetics Information

TERMS & AGREEMENT

A CHARGE WILL BE MADE FOR BROKEN APPOINTMENTS UNLESS 24 HRS NOTICE IS GIVEN.

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