Chiropractic Intake Form
Download a blank fillable Chiropractic Intake Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Chiropractic Intake Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
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The information collected in this form allows us to provide the best professional care.
Please fill it out to the best of your ability.
The Palliser Chiropractic Clinic is participating in a University of Lethbridge and Canadian Memorial
Chiropractic College research project. At some point you may be contacted for participation in this
project. No data collected will be used without your expressed and written permission.
Your personal information:
Date
First Name
Last Name
Birth Date
Sex
Male
Female
Age
Height
Weight
Mailing Address
City
Postal
Code
Cell Ph.
Home Ph.
Work Ph.
e-mail Address
Occupation
Education
Marital Status
Who may we thank
for referring you?
Your health insurance information:
To assist us in direct billing your insurance company, please provide your health and insurance information. For
information about your insurance coverage please call your insurance provider.
Alberta Health Care
Insurance Provider
Number
Plan/Group Policy
Renewal Date
Number
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