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Adolescent Chiropractic Forms

Adolescent Patient Intake and Consent

Parents, please complete the information in this form for any patient 5-12. This will be required before any treatment can be done for the child.

Insurance Information

Please include any insurance info you can for your first visit.

Compliance Form

Please complete, sign, and bring with you to your initial appointment.

Cancellation Policy

Please complete, sign, and bring with you to your initial appointment.

HIPAA sign off

Please sign and bring this form to your first visit.

HIPAA privacy notice

Please review and retain for your records

Surgical History Form

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  • 2316 Wehrle Drive,  Williamsville, NY 14221   (716) 616-9000