Parent/Guardian

First name

Last name

Street Address

City

State

ZIP

Phone

Email

Emergency Contact

Emergency First Name

Emergency Last Name

Emergency Phone

What age group is your child?

Child Age Group

Child birthdate

Child First Name

Child Last Name

Child’s weight

Child Weight Pounds

Child Weight Ounces

Child’s height

Child Height Feet

Child Height Inches

Is your child currently in pain or experiencing any discomfort?

Child Current Pain

Yes

No

Please describe current health issues below.

Child Current Conditions More

Please list any current medications, health supplements or homeopathic treatments.

Medications Supplements Homeopathic

Please list any current treatments currently being undertaken with your child (ex. physical therapy, chiropractics, psychological, etc.)

Other Treatments

I understand the treatment here is not a replacement for medical care.
As such, the therapist/practitioner does not prescribe medical treatment of pharmaceuticals nor does he/she perform any spinal manipulations (unless specified under his/her professional scope of practice)
I understand that the treatment is not a substitute of medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.
I have stated all known conditions and take it upon my self to keep the therapist/practitioner updated on my baby’s health.
I understand that payment is due at the time of treament unless arrangements have been made otherwise.
I agree to give at least 24 hours notice of cancellation of appointment, otherwise will be expected to pay for session.

I acknowledge and accept the aforementioned treatment conditions and parameters and payment requirements.

Signature