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  • Thank you for taking the time to complete this form as fully and accurately as possible. Even questions that may not seem directly related to your main concern help us better understand you as a whole person. This information allows our doctors to prepare for your visit with intention and create a thoughtful, personalized care plan tailored to your unique needs.

  • New Patient Intake Form (Adult)

    Holistic Health Information
  • Format: (000) 000-0000.
  • Date Of Birth*
     - -
  • What is your biological sex?*

  • Chief Complaints

  • What are your primary health concerns? (Select all that apply)*
  • Are your health issues getting progressively worse?*
  • Is there anything that you have found that makes your symptoms better?*
  • Is there anything that you have noticed that makes your symptoms worse?*

  • Medical History

  • Are you currently taking any medications or supplements?*
  • Have you been diagnosed with any medical conditions?*
  • Have you ever been hospitalized other than for surgery?
  • Do you have a family history of any of the following:*

  • Systems Review

  •
  • Which digestive symptoms do you experience?*
  • Do you experience an intolerance to perfumes or chemicals such as bleach?*
  • Are you intolerant to shampoo, lotion, detergents, etc?*
  • Do you suffer with constant or frequent skin outbreaks?*
  • Do you have a history of gall bladder issues / gall stones?*
  • Choose all that apply:*
  • Do experience any of the following symptoms?
  • When is your energy at its lowest?*
  • Do you experience any of the following neurological symptoms? *
  • Have you or a close family member been diagnosed with Alzheimer's, Parkinson's, ALS, MS, etc?

  • Lifestyle

  • How would you describe your current diet?*
  • How often do you exercise?*

  • Previous Care

  • Have you had any lab work done in the past year?*
  • Which of the following labs have you had done?
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  • Have you ever been seen by a chiropractor before?*
  • Have you ever worked with a functional medicine practitioner before?*

  • Additional Information

  •
  • Is there a particular doctor in our office that you would like to request?*
  • We provide a variety of services in our clinic. Is there a specific type of therapy you are most interested in?

  • Office Policy


    Thank you for choosing Chiropractic Advantage for your health care needs. We are committed to providing you with exceptional care and service. To ensure we can serve you and all our patients effectively, we've outlined our office policies below.


    Payment Policy


    We operate on a simple, straightforward payment model. Payment is due in full at the time of service, which allows us to keep our fees competitive and focus on your care rather than insurance paperwork. We accept cash, checks, and credit/debit cards.
    Please note that we do not accept payment on lien for personal injury or worker's compensation cases.


    Health Insurance


    Many health insurance policies now cover alternative health care. However, we've found that a significant number of plans have co-pays that exceed our fees. For this reason, we do not submit claims directly to insurance companies. You are welcome to file for reimbursement on your own, though we cannot guarantee what your insurance will cover.


    Respecting Everyone's Time


    Our goal is to provide quality, timely care to every patient. When you schedule an appointment, you're reserving dedicated time with our providers-time that becomes unavailable to other patients who may need care. We deeply appreciate your consideration in helping us serve everyone effectively.


    Appointment Reminders and Confirmation


    We'll send you text and email reminders about your upcoming appointments. To help us manage our schedule efficiently, we ask that you confirm your appointment through our text reminder system or by calling our office. Any unconfirmed appointments will be automatically released back into our schedule at 6 PM the day before, making that time available to other patients. Same-day appointments are automatically confirmed.


    If You Need to Cancel or Reschedule


    We understand that life happens! If you need to cancel or reschedule, we simply ask that you let us know by 5 PM on the day before your appointment. This advance notice allows us to offer your appointment time to another patient who may be waiting for care.


    To cancel or reschedule:


    • Reply to your appointment confirmation text, or
    • Call our office during business hours:

    Monday-Thursday: 8 AM-6 PM
    Friday: 8 AM-12 PM


    Late Cancellations and Missed Appointments


    To help us maintain appointment availability for all patients, we have a $50 fee for cancellations made after 5 PM the day before your appointment, or for missed appointments without notification. For new patients, a late cancellation or no-show for your first appointment will result in the full new patient fee.

    We truly appreciate your partnership in helping us provide excellent care to our entire patient community.

    I have read and understand the office policies outlined above. The information I have provided is accurate to the best of my knowledge.

    Print Name:

  • Date*
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