Intake Forms

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Existing Client Intake Form

As I switch over to an online scheduling portal, this is my intake form for my Existing Clients. Please click on the button below to add your contact information to the new portal. 

Existing Client

Newborn to Two Year old Health profile

For a new client age newborn up to 2 years old, please fill out this form for an initial visit. Please be as detailed as you can- it saves time at the initial visit for me to have all of the information and I can focus instead on my assessment and adjustments of your precious little one! 

Newborn - 2yo Health Profile

Childrens Health Profile (3yo-12yo)

For a new client age 3 up to age 12, please fill out this form for an initial visit.  Please be as detailed as you can-it saves precious time for me to be able to address a child's initial worry and concerns, and provides me more time for assessment and adjustments.  

Childrens Health Profile (3yo-12yo)

Health Profile

For new clients ages teen up through adult, please fill out this form for an initial visit.  Yes, there are a lot of questions... but there is also a lot about you that I do not know. Please provide the details.  The more I understand you, the better I can develop a plan to personalize your adjustment! 

Health Profile

Consent Forms

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Informed Consent to Chiropractic Care

This is my Informed Consent to Chiropractic Care document. I have tried to condense as much as possible, and it is good information. Please read and sign. 

Informed Consent to Care

HIPAA Acknowledgment

This is the HIPAA Acknowledgement form, it is just one of those necessary forms. 

HIPPA Acknowledgment

Notes on Privacy Practices

This is a read-only document about the HIPAA Acknowledgment. When you enter your initials on the Acknowledgement that you are aware of the details... this is the document I am referencing! 

Notes on Privacy Practices

Policies and Procedures

I have 2 policies and procedures I want all clients to be aware of:  the cancellation policy and the potential co-care communications.  This is how I know you have been made aware of them!

Policies and Procedures