Patient Intake Form

Name *

First

Last

Date of Birth *

Gender *

• Female
• Male
• Other:

Other Gender

Address *

Phone Number* *

Email

Do you have Extended Healthcare benefits? *

• Yes
• No

Plan Member

Insurance Company

Plan #

ID #

Have you ever received services from a CHIROPRACTOR? *

• Yes
• No

Have you ever received services from a PHYSIOTHERAPIST? *

• Yes
• No

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

• Yes
• No

Have you ever received services from a MASSAGE THERAPIST? *

• Yes
• No

Have you ever received services from an ATHLETIC THERAPIST? *

• Yes
• No

Submit