INTAKE FORM- ADULT PATIENT

 FALLS HEALING ARTS  
Adult Patient Information Form


Please fill out and submit prior to your first appointment

If you haven't already, give us a call to schedule your first appointment. 

(By submitting an intake form online without calling us,

does not guarantee the fastest response back to you for scheduling.) 

The information on these forms help our doctors and therapists determine what course of treatment to pursue. Chiropractic patients are asked to also bring their insurance card.

FALLS HEALING ARTS, S.C. Intake Age 4-17

1.PATIENT INFORMATION 

2. INSURANCE INFORMATION

3. ACCIDENT INFORMATION

4. PATIENT CONDITION

5. HEALTH HISTORY

Name and address of other doctor(s) who have treated you for your condition?

Date of last:

HABITS

6. Injuries/surgeries 

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