Child’s Full Name:
Guardian’s Full Name: As it appears on your ID, Insurance card or medical record
What is your email address? *We'll use this to keep you up to date with office news and announcements
What is your phone number? *Please enter the best available phone number to reach you.
What is your complete home address? *Street number, City, State, and Zip Code
What is your date of birth?
Parent/Guardian's Age:
Is your child 0 – 5 years old?YesNo
Child’s Birth was at: At homeAt a birthing centerAt a hospital
My Obstetrician / Midwife / Family Physician wasPlease provide full name.
At how many months did your child:
Respond to sound?
Follow an object?
Hold head up?
Sit alone?
Teethe?
Crawl?
Walk?
Hospitalization/Surgical History: please list all surgeries and hospitalizations, including the year
Please list any major injuries, accidents, falls, and/or fractures your child sustained in his /her lifetime:
Is/was your child breastfed? YesNo
At what age was formula introduced?
At what age did solid foods began?
Please list any food or drink intolerance:
Any illness of mother during pregnancy? YesNo
List any drugs/medications, including over the counter, taken during pregnancy:
List any supplements taken during pregnancy:
Has your child received any vaccinations? YesNo
If yes, were there any negative reactions?
Has your child received any antibiotics? YesNo
Any difficulty with breastfeeding? YesNo
Does your child have any behavioral problems?YesNo
Does your child have any night terrors, sleepwalking, or difficulty sleeping? YesNo
Child’s Age:
Have you or your child ever had chiropractic care before? YesNo
Is this appointment related to an accident or trauma? YesNo
Is your child receiving care form other health professionals? YesNo
If yes, please name them and their specialty:
Please list any drugs or medications your child is taking:
Please list any vitamins/herbs/homeopathics/other your child is taking:
Please list any allergies your child has:
What health concern brings your child to our office?
When did symptoms first begin?
How did it start? SuddenGradualPost-injuryNot Sure
What makes the problem better?
What makes the problem worse?
Has your child had a similar condition? YesNo
Has your child had treatment for this problem before? YesNo
Does your child eat well? YesNo
Does your child drink water? YesNo
Does your child have regular bowel/bladder movements? YesNo
Has your child ever been checked for vertebral subluxation? YesNoNot Sure
Average number of hours of screen time your child watches per week
I do hereby authorize the Doctors & Licensed Acupuncturists of Premiere Healthcare to administer such care that is necessary for my particular condition(s). This care may include, but are not limited to, review of medical history, examination, acupuncture, herbal medicine, spinal or extremity adjustments, soft tissue or manual therapies (myofascial release, cupping, gua-sha, tui-na, qigong), physiotherapy modalities (ice, heat, electric stimulation), nutritional and lifestyle counseling and/or laser therapy that is advisable, and necessary for my health condition(s).
I understand, that if recommended, herbal medicine needs to be prepared and teas need to be consumed according to instructions provided orally and in writing. The herbs may have unpleasant smell or taste. I will immediately notify my practitioner or clinical staff member of any unanticipated or unpleasant effects associated with the treatment or consumption of herbs.
Furthermore, I authorize and agree to allow the Doctors & Acupuncturists of Premiere Healthcare to work with my health condition(s) through the use of acupuncture needling, spinal adjustments, various soft tissue or manual therapies, physiotherapy modalities, nutritional supplements, herbs and homeopathic remedies, rehabilitative exercises and/or laser therapy for the sole purpose of postural and structural restoration to allow for normal biomechanical and neurological function. I have had an opportunity to discuss with one of the Doctors or Acupuncturists of Premiere Healthcare and/or with other office or clinic personnel regarding the nature and purpose of recommended treatment and other procedures related to my health care.
I understand that I am responsible for all fees incurred for the services/products/durable medical equipment provided and agree to ensure full payment of all charges. I further understand that a fee for services or products rendered will be charged and that I am responsible for this fee whether results are obtained or not.
I understand and am informed that as in the practice of medicine and dentistry, in the practice of Acupuncture, Chiropractic & Oriental Medicine there are risks to treatment including, but not limited to fractures, disc injuries, burns, stroke, dislocations, sprains, headaches, temporary increased soreness or pain, nausea or lightheadedness and emotional release. I do not expect the Doctor or Acupuncturist to be able to anticipate and explain all risks and complications of a given procedure on any visit, and I wish to rely on the Doctor or Acupuncturist to exercise judgment during the procedure which they feel at the time, based upon the facts then known, is in my best interest. The Doctor or Acupuncturist will not be held responsible for any health conditions or diagnoses which are pre-existing, given by another health care practitioner, or are not related to the conditions treated at this clinic.
I understand there are other forms of treatment, including drugs and surgery, which could be treatment options for my condition(s), but at this time, I choose acupuncture, chiropractic, nutrition and/or oriental medicine. I understand that acupuncture or oriental medicine is not a replacement for diagnostic medical procedures and that an Acupuncturist does not diagnose according to standard medical practice. I further acknowledge that my practitioner is not a medical doctor, Doctor of Osteopathy or Doctor of Physical Therapy and does not claim to practice within the scope thereof.
I have read or have had read to me, the above consent. I have been told of the risks also had the opportunity to ask questions about this consent, and by submitting this form I agree to the above-above named procedures. I intend this consent form to cover the entire course of care for my present condition and for all future conditions(s) for which I seek treatment.
Your appointments and well-being are very important to us. We understand that sometimes unexpected delays can occur, making schedule adjustments necessary. If you need to cancel or change your appointment, we require a 48 Hour Notice, prior to your scheduled appointment so that we may have time to offer the opening to another patient.
By scheduling appointments, you agree to the terms of our no-show/late cancel/ late reschedule policy. We reserve the right to charge a Cancellation Fee of $50 for all appointments cancellations or late rescheduling (less than 48 hours prior). We cannot bill your insurance for no shows.
Cancellation fees will be charged to your card on file the day of your scheduled appointment. If no card on file, payment of cancellation fee will be required prior to securing your next appointment. Repeated violations of our cancellation policy will result in the patient being required to pay the full price of any scheduled services upfront or upon any cancellation with less than 48-hour notice.
I have read and understand the Premiere Healthcare appointment No-Show/Late Cancellation Policy and agree to the terms noted herein.
By submitting this form you acknowledge and agree to the above terms and conditions.
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