Wellington Family Chiropractic Pediatric History Form

Wellington Family Chiropractic Pediatric History Form
Patient Information
Patient's Name*

First NameMiddle NameLast Name
Gender*
Birth Date*

MonthDayYear
Date
Age*
Birth Height
Birth Weight
Current Height
Current Weight
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone*
Please enter a valid phone number.
Mother's Mobile Phone
Please enter a valid phone number.
Father's Mobile Phone
Please enter a valid phone number.
Mother's Name
Mother's Birth Date

MonthDayYear
Date
Father's Name
Father's Birth Date

MonthDayYear
Date
Primary Physician
City & State
Date of Last Visit

MonthDayYear
Date

Insurance Information
If you do not have health insurance, please check this box and skip this section.

I do not have insurance.
Primary Insurance Company
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Secondary Insurance Company
Member ID Number
Policy Holder's Name
Relationship to Patient
Policy Holder's SSN
Policy Holder's Birth Date

MonthDayYear
Date
Who is responsible for this bill?

MotherFatherOther
Responsible Party's SSN

Authorization
I understand that I am directly and fully responsible to Wellington Family Chiropractic for all fees associated with chiropractic care my child receives. It has been explained to me that all fees paid for x-rays taken at this office are for the examination, and that I am only entitled to a copy of the written imaging report, which explains the results of my child’s examination. The actual films themselves are considered part of my child’s original health record and as such will not be released to anyone, under any circumstances, including me. I further understand and agree that they are the sole legal property of this practice and that by law the doctor must retain these films for a period of no less than four (4) years.

The risks associated with exposure to ionization, and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request, and authorize imaging studies, and chiropractic adjustments, for the benefit of my minor child, for whom I have the legal right to select, and authorize health care services on behalf of.
Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.
Signature*

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Date*

MonthDayYear
Date
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Wellington Family Chiropractic Pediatric History Form

Patient Information

Insurance Information

Current Health

Health History

Authorization