Patient Intake Form

Are you looking for a way to improve your health naturally? Chiropractic care is a great option. It's like building a house – you need to follow a specific order to make sure everything stands strong and works correctly. Without a solid foundation, your walls would be weak and eventually collapse. The same is true for your body. To repair itself fully and correctly, your body needs to go through a particular plan of care. In chiropractic, this plan is divided into three phases. Keep reading to learn more or click here to schedule your first appointment.

Section 1

Personal Information

First Name *

Last Name *

Date of Birth

Phone *

Email *

Home Address

Section 2

Insurance Information

Insurance Provider

Member ID

Section 3

Visit Preferences & Chief Complaint

Preferred Location

Service of Interest

Preferred Provider

Planned Visits

Chief Complaint / Reason for Visit

Signature

Patient Signature

Date

By typing your full name, you acknowledge this as your legal electronic signature.

I certify that the information provided above is accurate and complete to the best of my knowledge. I authorize Graybar Chiropractic & Rehab to use this information for treatment, billing, and administrative purposes.