Pediatric Intake Form

Welcome to Excelsior Chiropractic!

Pediatric History Form 

Child's Current Problem:

My Health Insurance

I understand and agree that health and accident insurance policies are an arrangement between an insurance carrier and myself . I understand that the Doctor's Office will provide any necessary reports and forms to assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's Office will be credited to my account upon receipt.

If your insurance changes in the future, please notify the front-desk upon check-in.

Policy Holder Information

Missed Appointments

We strive to provide you with the utmost professionalism and excellence of service. Our commitment to your well-being and health is something we take seriously.

We care about you and realize it would be a disservice to you if we did not emphasize the importance of your own commitment to the care you need and to the actions we recommend to you.

• Your faithfulness to the recommended number of adjustments is key to ensuring optimum results.
• With the exception of emergencies, it is vital that you keep all your appointments. Reminder cards and text messages are provided to help you save the date. If you need to re-schedule your appointment, please call our office.

Thank you for your understanding. We greatly appreciate you as our patient and strongly desire excellent results and success for you!

Authorization for Care:

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives. if I have not provided all the necessary documents and information by the time of the second visit, I agree to make payment in full on a cash basis.

The risks associated with exposure to ionization, and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request, and authorize imaging studies, and chiropractic adjustments, for the benefit of my minor child, for whom I have the legal right to select, and authorize health care services on behalf of.

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse /former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.

I understand and agree to all the information written above.