Wellington Family Chiropractic Pediatric History Form

  • Wellington Family Chiropractic Pediatric History Form

  • Patient Information

  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Mother's Birth Date
     - -
  • Father's Birth Date
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  • Date of Last Visit
     - -

  • Insurance Information

  • Policy Holder's Birth Date
     - -
  • Policy Holder's Birth Date
     - -
  • Who is responsible for this bill?

  • Current Health

  • Purpose of this visit:*

  • If your child is currently experiencing pain or discomfort, please complete the following.

  • Have you seen any other doctors for this problem? If yes, who and how long ago?
  • How is the problem now?

  • Health History

  • Has your child ever suffered from the following? Please check all that apply, and provide pertinent details below.*

  • If your child has received chiropractic treatment before, complete the following.

  • 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.

  • Date*
     - -
  • Should be Empty: