• Infant New Patient Forms

  • Patient Information

  • Today's Date:*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Does the patient have any siblings?*

  • How can we help your child?

  • Please check boxes on any other areas you would like addressed:

  • Pregnancy History

  • Did the infant's mother experience any complications during her pregnancy? (check all that apply)*
  • Was the mother under chiropractic care during pregnancy?*
  • Has the infant had previous chiropractic care?*

  • Birth History

  • Type of Birth (check all that apply):*

  • Growth and Development

  • Infant Feeding:*
  • Has your child ever taken antibiotics?*
  • Has your child ever been hospitalized?*
  • Have you vaccinated your child?

  • Authorization of Care of Minor

    The statements made on this form are accurate to the best of my knowledge. I hereby authorize this clinic and its doctor(s) to administer care as they so deem necessary to my son/daughter/ward.

  • DATE:*
     / /
    2 digit month, 2 digit day, 4 digit year
  •  
  • Should be Empty: