Patient Intake Form

Name *

First

Last

Date of Birth *

Gender *

Other Gender

Address *

Phone Number* *

Email

Do you have Extended Healthcare benefits? *

Plan Member

Insurance Company

Plan #

ID #

Have you ever received services from a CHIROPRACTOR? *

Have you ever received services from a PHYSIOTHERAPIST? *

Have you ever received services from a CHIROPODIST (FOOT SPECIALIST)? (copy) *

Have you ever received services from a MASSAGE THERAPIST? *

Have you ever received services from an ATHLETIC THERAPIST? *