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New Patient Intake – Adult

This comprehensive eight-part chiropractic intake form collects important information from new patients at chiropractic clinics. In addition to contact information, family physician, and emergency contact, it asks an extensive list of medical and health questions. The intake form also includes any current medications the patient is taking, lifestyle habits, and whether they wear orthotics or artificial joints. Finally, the form also contains patient consent for chiropractic treatment and authorization of their responsibility to promptly pay for the treatment not covered by insurance.