• CHILDREN’S CHIROPRACTIC HISTORY

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  • Prenatal History:

  • Labor/Birth History:

  • Infant Feeding History:

  • Medical History:

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  • No. of antibiotics prescribed:

  • Developmental History:

  • During the following times, a child’s spine is most vulnerable and should routinely be checked by a
    Doctor of Chiropractic for Prevention and Early Detection of the Subluxation Complex.
    At what Age was your child able to:

  • I hereby authorize this clinic and its Doctor(s) to administer care as they so deem necessary to
    My Son / Daughter / Ward.

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  • Signature on file and authorization to release medical information:
    I HEREBY AUTHORIZE PAYMENT OF INSURANCE BENEFITS DIRECTLY TO THE DOCTOR FOR
    SERVICES PROVIDED. I FURTHER AUTHORIZE THE DOCTOR TO RELEASE ANY INFORMATION
    REQUIRED TO PROCESS INSURANCE CLAIMS.

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  • Should be Empty: