INTAKE FORM- AGES (INFANT- 3 YEARS)

FALLS HEALING ARTS
Intake Age Infant-3 years

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 

IN CASE OF EMERGENCY, CONTACT

2. INSURANCE INFORMATION

3. ACCIDENT INFORMATION

4. PATIENT CONDITION

6. Injuries/surgeries your child has had

Person Ultimately Responsible For Account

We invite you to discuss frankly with us any questions regarding our services. The best health services are based on a friendly, mutual understanding between provider, parent and patient.


Our office policy requires payment in full for all services at the time of visit. The person bringing the patient to this office is responsible

for charges unless other arrangements have been made with the business manager. If the account is not paid within 90 days of the date of service, and no financial arrangements have been made, you will be responsible for any expenses incurred in collecting your account.


I understand the above information, guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform the office of any changes in my child’s medical status.

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