Chiropractic Client Intake Form

Information you will need

• HEALTHCARE PROVIDER ONLY: What's the name of the healthcare facility?
• What's your street address?
• What city do you live in?
• What state do you live in?
• What's your mobile phone number?
• What's your SSN?
• What's your e mail?
• What's your spouse's name?
• Who's your emergency contact?
• What's your relationship to the emergency contact?
• What's your date of birth?
• Do you drink caffeine?
• Do you drink alcohol?
• Do you want to upload an image? af image
• How often do you exercise?
• What's your first name?
• What's your home phone number?
• What's your work phone number?
• How would you like to be contacted?
• Who's your primary care physician?
• Have you been to a chiropractor before?
• What's your primary care physician's phone number?
• Where did you receive treatment (if applicable)?
• What's your employer's name (if applicable)?

…and 159 more fields in the PDF.

Completed by the client.

The form includes 2 signature lines, a notary acknowledgment.