Hello Chiropractic New Client Intake

New Client Intake Form

Page 1 - Contact Information
**All care in this office is NOT covered or reimbursable by any insurance or 3rd party**

*You are responsible for payment prior to care by cash or credit/debit/HSA card*
Name*

First NameLast Name
Preferred Name*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number (mobile)*

Area CodePhone Number
Birthdate*

MonthDayYear
Date
Marital Status

SingleMarriedWidowedOther
Spouse's or Significant Other's Name*

First NameLast Name
Children at Home
Referred by?
Would you like the doctor to pray with you today?
My office is different than over 95% of chiropractors. Do not expect it to be the same as any previous chiropractic experiences.
What kind of work do you do?
Favorite Hobbies or Interests
Have you been to a chiropractor before?*

YesNo
Approximate date of last visit
Good results?

YesNo
Please explain what you liked / disliked about your previous chiropractic experience(s)
Jesus looked at them and said, “With man this is impossible, but with God all things are possible.” Mt 19:26

Adult Health Intake

Page 3 - Health Direction
My goal in this model of care is to help prevent dis-ease, promote good health, and prolong and enhance your overall quality of life. This is NOT a medical necessity and is not covered by any insurance. I will NOT submit notes, claims, or bills for any care in my office.
Are you healthier today than you were 5 years ago?

YesNoNot sure
Will you be more healthy in 5 years than you are today?

YesNoNot sure
If yes, what will you do to make sure you are?
If no or not sure, what COULD you do to start getting happier and healthier?
What would you like your health to look like 5 years from now?
Give all your worries and cares to God, for he cares about you. 1 Pet 5:7

Adult Health Intake

Page 4 - Informed Consent to Care
Signature

Clear
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New Client Intake Form