Chiropractic Intake - Pediatric




During pregnancy, did the mother:

Check any of the following your child experienced immediately after birth:*
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Is the purpose of this visit related to*
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Has this condition
How long ago?*
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Please check each of the diseases or conditions that your child has now or has had in the past. While they may seem unrelated to the purpose of the adjustment, they can affect the overall diagnoses and recommended care plan. 

Has your child ever suffered from:*
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Have you or anyone else noticed that your child is nervous, twitches, or exhibits rocking behavior?

Goals for Care

Children see Chiropractors for a variety of reasons. Some go for relief of pain, some go to correct the cause of their pain, and others for correction of whatever is malfunctioning in their bodies. Your Doctor will weigh your needs and desires when recommending your care plan. Please check the type of care desired so that we may be guided by your wishes whenever possible. 

I want the Doctor to select the type of care appropriate for my condition


Have you chosen to vaccinate your child?
If yes, please check all vaccinations your child has received


I hereby authorize the Doctor's of True Chiropractic, and whomever they may designate as their assistants to administer Chiropractic care to work with my child through the use of adjustments and procedures to the spine, as the Doctor deems appropriate. 

I understand that I am directly and fully responsible to this office for all fees associated with chiropractic care my child receives. I agree that I am responsible for all the bills incurred at this office. The Doctor will not be held responsible for any pre-existing medically diagnosed conditions nor for any medical diagnosis. I also understand that if my child's care is terminated, any fees for professional services rendered to me will become immediately due and payable. I understand that agree that health and accidental insurance policies are an arrangement between an insurance carrier and policy holder. I understand that the Doctor's office will prepare any necessary reports and forms and assist me in collecting from the insurance company and that any amount authorized to be paid directly to the Doctor's office will be credited to my account upon receipt. I hereby authorize assignment of my insurance rights and benefits (if they apply) directly to the provider of services rendered. 

The risks associated with exposure to x-rays and spinal adjustments have been explained to me to my complete satisfaction, and I have conveyed my understanding of these risks to the doctor. After careful consideration I do hereby request and authorize imaging studies and chiropractic adjustments for the benefit of my minor child for whom I have the legal right to select and authorize health care services on behalf of. I hereby request and authorize this office to administer healthcare as deemed necessary to my dependent minor child. This authorization also extends to include diagnostic imaging, laboratory and other testing at the doctor's discretion.

Under the terms and conditions of my divorce, separation or other legal authorization, the consent of a spouse/former spouse or other guardian is not required. If my authority to so select and authorize this care should change in any way, I will immediately notify this office.*
Please select at least one option

Thank you for taking the time to fill out this form.

Contact Us


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Office Hours

Lake Tahoe Wellness Center


2:00 pm-6:30 pm


9:00 am-1:00 pm


2:00 pm-6:30 pm


9:00 am-1:00 pm


Classes And Appointments Available


Classes And Appointments Available


Classes And Appointments Available