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Home | New Patients | Online Forms | Chiropractic | Pediatric Health History - New Patient
In order to provide you the best possible wellness care, please complete this form
Nature of Injury
Name of the Insured _____________________________________________
I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself. I understand and agree that all services rendered to me and charged are my personal responsibility for timely payment. I understand that if I suspend or terminate my care/treatment, any fees for professional services rendered to me will be immediately due and payable.
Patient's signature _______________________________________________
Parent or Guardian's signature __________________________________
If your child has had any of the following diseases, please fill in age at time of occurence
Please list the age that your child...
According to the National Safety Council, approximately 50% of children fall head first from a high place during their first year of life (i.e. a bed, changing table, high chair, down the stairs, etc...)