Pediatric New Patient Form

Pediatric History Form 

Health History 

Birth History

When did your child:

Family History:

Do any of your child's relatives have any of the following conditions?

Maternal 

Paternal 

Sibling

hereby grant permission for my child to receive a chiropractic evaluation as well as chiropractic care which may include history, spinal scans, physical examination, manipulation, laser, heat/ice, ultrasound, therapeutic exercises, electrical stimulation or any service deemed medically necessary by West Hartford Chiropractic. I also understand that West Hartford Chiropractic cannot guarantee any results. I understand that I am responsible for any services received not covered by insurance and am responsible for obtaining a referral if required.