New Patient Intake

All fields with an asterisk (*) are required. Please fill in all these fields to ensure your intake can be submitted without errors.

If you try to submit the form and get a field error – after correcting that error, the error message will not go away until you re-submit the form.

Client Name(Required)
First Last
Sex(Required)
Age (number only please)(Required)
Birth Date(Required)
Marital status(Required)
Address(Required)
Street Address City State ZIP Code
Mailing Address (if different than home)
Street Address City State ZIP Code
Home phone #
Cell phone #(Required)
Work phone #(Required)
Email(Required)
Insurance Information
Will you be using insurance?(Required)
- Yes
- No
Name of Insurance company(Required)

(put N/A if not using insurance)
Group #(Required)

(put N/A if not using insurance)
Insurance Company Phone #(Required)

(put N/A if not using insurance)
Insurance ID# (include all letters and numbers)(Required)

(put N/A if not using insurance)
Who is the Insurance Subscriber? (the person who subscribes to the insurance plan)(Required)
- Myself
- Someone Else
Insurance Subscriber (name of the person the insurance is under - employee/family member)(Required)
First Last
Date of Birth of Insurance Subscriber(Required)
Subscriber's relationship to patient(Required)
Emergency Contact
Emergency contact(Required)
Relationship to Contact(Required)
Emergency Contact Phone(Required)
Additional Information and History
Referred by?
Your Family Doctor
Your Chiropractor
List any medications you are currently or recently using, or "none":(Required)
List any vitamins/herbal supplements you are currently or recently using, or "none":(Required)
List all Allergies (medications/seasonal foods), or "none" if you have no known allergies:(Required)
Your goal for your visit(Required)
Have you been diagnosed with any chronic conditions?(Required)
Have you ever been hospitalized?(Required)
Are you currently on any special diet?(Required)
List chronic conditions and diseases that run in your family:

New Patient Intake

Insurance Information

Emergency Contact

Additional Information and History