Funnell Family Chiropractic Child Entrance Form (Age 2

Have you chosen to have your child vaccinated?

Yes

Has your child had surgery:

Yes

If yes, please list: ___________________________________________

Has your child been diagnosed as having Congenital Hip Dislocation (Clicky Hips)?

Yes

Has your child had any spinal x-rays taken?

Yes

Has your child ever had any broken bones/fractures?

Yes

No Please List: _______________________________

______________________________________________________________________________________________________

Accident History:

Is / has your child been involved in any high impact or contact type sports (i.e. soccer, rugby, gymnastics, martial arts etc.)?

Please list: ______________________________________________________________________________________________

Please list any accidents your child has had: ____________________________________________________________________

________________________________________________________________________________________________________

Is there anything you think we should know about your child or their health? ___________________________________________

________________________________________________________________________________________________________

Please state the reason for your visit to us today: ________________________________________________________________

________________________________________________________________________________________________________

Do you have a preferred appointment time?

Yes/No When? _______________________________________________

On your visit today you will see the Chiropractor for a consultation; they will check your child’s spine and

gently make any chiropractic adjustments if necessary.

Authorization for care of a minor

I hereby authorize this office and its Chiropractors to administer care to my son/daughter as they deem necessary. I

clearly understand and agree that I am personally responsible for payment of all fees charged by this office.

Name of Parent/Guardian: _________________________________________________________________________

Signed: __________________________________________________ Date: _________________________________

Thank you for taking the time to complete this form.

We look forward to helping your child achieve the best possible health with chiropractic.

We are here to serve you, and encourage you to ask questions.

Your participation is vital and will help determine your results.

Please ensure your mobile phone is switched off.

Funnell Family Chiropractic Child Entrance Form (Age 2 - 12) Page 2