Pediatric Intake Form

I understand that chiropractic care is a specialized healing practice that is distinct from traditional medicine. It does not claim to diagnose, treat, or cure any specific disease or condition. The care I receive in this practice is guided by the best available evidence and is focused on identifying and addressing vertebral subluxations to support my overall health and wellness. I am aware that the Webster Technique, as described by the International Chiropractic Pediatric Association, is a specific chiropractic approach designed to improve nervous system function, balance pelvic muscles and ligaments, and alleviate uterine torsion. This technique is intended to reduce intrauterine constraint and help optimize the baby’s position for birth. I give permission for this office to contact me for appointment confirmations, scheduling needs, or to send health-related updates such as emails, letters, or other forms of communication as part of my care experience. I acknowledge that I may request a copy of the Privacy Policy at any time, which outlines how my personal health information is protected. I accept full responsibility for the timely payment of all services provided. Furthermore, I confirm that the information I have provided is complete and accurate to the best of my knowledge. I affirm that I have not misrepresented the nature, severity, or cause of my health concerns. By signing below, I confirm my understanding and agreement to the terms of care and office policies outlined above.