• It is a pleasure to welcome you to our family of happy and healthy chiropractic patients. Please let us know if there is any way we can make you and your family feel more comfortable. Many types of stressors (physical, mental, and chemical) can interfere with your child's growing brain, spine and nervous system. To help us serve you better, please complete the following information. We look forward to working with you to build better health for your family.

  •  / /
    Pick a Date
  •  / /
    Pick a Date

  • # of Doses of antibiotics your child has taken:

  • Prenatal History

  • Gestational Age:
    Baby was born at weeks and days.

  • Feeding History

  •  
  • Developmental History

    (to the best of your knowledge)
  • Your child's spine is vulnerable to stress and should routinely be checked by a Doctor of Chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference Spinal nerve interference can affect the following. At what age was your child able to:

  • According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, down stairs)

  • Lifestyle

    (please check al that apply)
  • I hereby give my consent for my child to be examined by the Chiropractor using chiropractic methods as seen fit.

  • Clear
  • PHOTO RELEASE FORM

  • We love to have kids' pictures in our office! If you would allow us to have your child's picture in the office, please sign below.

    For valuable consideration, I hereby irrevocably consent to and authorize the use and reproduction by Southern Family Chiropractic LLC, or anyone authorized by Southern Family Chiropractic LLC, of any and all photographs/videos which were taken of my child, for the purposed of promotional TV, website, social media and/or print ad whatsoever, without further compensation to me. All negatives and positives, together with the prints shall constitute the property of Southern Family Chiropractic LLC, solely and completely. Any information voluntarily provided by a patient shall also be used in conjunction with the above listed information for purposes previously mentioned. Confidentially, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. I authorize Southern Family Chiropractic LLC to share this information via their website and their Facebook/socia media including Twitter and Instagram, and for use in the office. All other unrelated patient information shall remain private and protected (according to Health Information and Privacy Act laws.

  • Clear
  •  / /
    Pick a Date
  • AS YOUR HEALTHCARE PROVIDER, WE ARE LEGALLY RESPONSIBLE FOR YOUR CHIROPRACTIC RECORDS. WE MUST MAINTAIN A RECORD OF YOUR X-RAYS IN OUR FILES.

    AT YOUR REQUEST, WE WILL PROVIDE YOU WITH A COPY OF THEPLEASE NOTE: IF X-RAYS ARE NECESSARY, THEY ARE UTILIZED IN THIS OFFICE TO HELP LOCATE AND ANALYZE VERTEBRAL SUBLUXATIONS. THESE X-RAYS ARE NOT USED TO INVESTIGATE FOR MEDICAL PATHOLOGY.

    THE DOCTORS OF SOUTHERN FAMILY CHIROPRACTIC DO NOT DIAGNOSE OR TREAT MEDICAL CONDITIONS; HOWEVER, IF ANY ABNORMALITIES ARE FOUND, WE WILL BRING IT TO YOUR ATTENTION SO THAT YOU CAN SEEK PROPER MEDICAL ADVICE.

     IF YOUR CHILD IS AN INFANT OR UNDER THE AGE OF FIVE, IT IS UNLIKELY THEY WILL NEED CHIROPRACTIC POSTURAL XRAYS. HOWEVER, PLEASE SIGN BELOW FOR FUTURE REFERENCE.

    BY SIGNING BELOW YOU ARE AGREEING TO THE ABOVE TERMS AND CONDITIONS

  • Clear
  •  / /
    Pick a Date
  •  
  • Should be Empty: