Infant & Toddler Intake Form

Yor Privacy Rights
We are committed to protecting your health information. Your information may be used for treatment, payment, and healthcare operations as required by law. A copy of our Notice of Privacy Practices is available at the front desk and upon request.

Chiropractic care focuses on supporting the nervous system and musculoskeletal system so the body can function, adapt, and heal as efficiently as possible. Care is gentle, individualized, and appropriate for each person's age, size, and health history. I understand that chiropractic care does not diagnose or treat disease, that results may vary, and that no guarantees have been made regarding outcomes

Payment is due at the time of service unless prior arrangements are made. Belleair Bluffs Chiropractic accepts some insurance plans. Insurance benefits are verified as a courtesy and are not a guarantee of payment. Patients are responsible for any balance not covered by insurance

From time to time, photos or videos may be taken for clinical documentation, education, or marketing purposes. No identifying information will be shared without your explicit permission. Participation is completely voluntary and will not affect your care