• Chiropractic Intake Form

  • Patient Information

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  • Medical Data

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  • Authorization and Consent

    • I confirm that all information given in this form is true, complete, and accurate.
    • I released this organization for any responsibility in case of accident, illness, or injury.
    • I acknowledge that no assurance was offered about the outcome.
    • I acknowledge that I received an Informed Consent document and the health staff explained it to me thoroughly.
    • HIPAA:I confirmed that I have read and received the HIPAA Privacy Practices of this chiropractor's office regarding protected health information
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