Adult Intake Form

Address

771 North Congress Street Jackson, MS 39202
New Practice Member Intake

Please fill in the form below
TERMS OF ACCEPTANCE

CHIROPRACTIC HAS ONLY ONE GOAL AND THAT IS TO REMOVE NERVE INTERFERENCE CAUSED BY A MISALIGNMENT OF SPINAL BONES. IT IS IMPORTANT THAT YOU UNDERSTAND THAT DIAGNOSING CONDITIONS, TREATMENT OF CONDITIONS, AND REMOVING PAIN IS NOT THE GOAL OF THIS OFFICE. LOCATING, ASSESSING, AND CORRECTING VERTEBRAL SUBLUXATION IS THE ONLY GOAL OF THIS OFFICE. ALTHOUGH THIS OFFICE MAY RELIEVE YOU OF SOME PAIN, MAINTAINING YOUR HEALTH AND FAMILY’S HEALTH THROUGH REGULAR SPINAL CHECKUPS AND SPINAL ADJUSTMENTS IS OUR PRIMARY GOAL.

"I understand that I will pay a total value of $100 for the initial visit. The initial visit consists of history taking, neurological chiropractic examination, reading of the radiology films, determining a uniquely designed care plan, goal setting, and the report of finding(s)."

Cancellation Policy:

A $25 charge will be applied the day of the appointment if you are more than 10 minutes late, and/or cancel/reschedule less than 24 hours prior to the appointment.

I THEREFORE ACCEPT CHIROPRACTIC CARE ON THIS BASIS
Signature*

Clear
Name

First NameMiddle NameLast Name
E-mail
Sex
Date of Birth

MonthDayYear
Contact Number:

Area CodePhone Number
Marital Status
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
In case of emergency...
Emergency Contact:

First NameLast Name
Relationship
Contact Number

Area CodePhone Number
CONSENT TO CARE FOR A MINOR CHILD

I HEREBY AUTHORIZE DR. SHIQUITA T. WHITE, DC AND WHOMEVER SHE MAY DESIGNATE AS ASSISTANTS TO ADMINISTER CHIROPRACTIC CARE AS SHE DEEMS NECESSARY TO MY CHILD MINOR/WARD.
Signature

Clear
NAME(S) OF CHILD/MINOR/WARD
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
Who referred you to the practice?
Health History

Chiropractic care is not a treatment or cure for any disease. Chiropractic is for the restoration of full function and communication within the body, from the brain to the tissues, so that you may express your bodies fullest potential for life and healing. While God Family Chiropractic Center’s only objective is to remove nerve interference it is mandatory you complete a health history. God Family Chiropractic Center will refer practice members when indicated as it is not our objective to diagnose, treat symptoms, or manage therapeutic care.
List the reasons why you are seeking specific neurological-based chiropractic care.
Have you seen a Chiropractor before? If so, type the name of the doctor or office.
Have you seen an M.D. about this? Yes No
Taking any medications, currently?

YesNo
If yes, please list it here
List any surgeries and accidents you have had in the past:
Do you experience any of the following? (Check all that apply)

Constipation (do not have at least one smooth bowel movement a day)Irritable bowelHeadachesAcneEczemaChronic yeast infectionsPMSIrritableHeavy bleeding (menstrual cycle)Blood clots (menstrual)InfertilityMiscarriageFatigue on a daily basis (no matter how much sleep you get)Low libidoInsomnia
Do you have a history of any of the following?

High blood pressureCholesterol imbalances (high or low)Thyroid conditionObesityAsthma (including childhood)Eating disorderFibroidsCancer
List the types of foods and drinks you would like to consume on a daily basis.
Eat to Live
What types of food are you addicted to (crave on a daily basis)?
What activities/movements/sports would you like to start performing or improve?
Move to Live
How many hours of deep sleep (no waking up) would you like to get on a nightly basis?
Sleep to Live
Who or what causes you the most emotional stress in your life?
Do you take full responsibility for your health, well-being, and overall quality of life?
What is keeping you from your health goals?
What's your typical body positioning at work?
How long are your daily workouts?
Is there anything else you would like the doctor to know?
List 3 family/friends who needs to be under specific neurological-based chiropractic care. (Even if they are in another state or country)
Campaign For Chiropractic
INFORMED CONSENT FOR CHIROPRACTIC CARE

CHIROPRACTIC CARE, LIKE ALL FORMS OF HEALTH CARE WHILE OFFERING CONSIDERABLE BENEFITS MAY ALSO PROVIDE SOME LEVEL OF RISK. THIS LEVEL OF RISK IS MOST OFTEN VERY MINIMAL, YET IN RARE CASES, INJURY HAS BEEN ASSOCIATED WITH CHIROPRACTIC CARE. THE TYPES OF COMPLICATIONS THAT HAVE BEEN REPORTED SECONDARY TO CHIROPRACTIC CARE

INCLUDE: SPRAIN/STRAIN INJURIES, IRRITATION OF A DISC CONDITION, AND RARELY, FRACTURES. ONE OF THE RAREST COMPLICATIONS ASSOCIATED WITH CHIROPRACTIC CARE OCCURRING AT A RATE BETWEEN ONE INSTANCE PER ONE MILLION TO ONE PER TWO MILLION CERVICAL SPINE (NECK) ADJUSTMENTS MAY BE A VERTEBRAL INJURY THAT COULD LEAD TO A STROKE.

PRIOR TO RECEIVING CHIROPRACTIC CARE IN THIS CHIROPRACTIC OFFICE, A HEALTH HISTORY AND PHYSICAL EXAMINATION WILL BE COMPLETED. THESE PROCEDURES ARE PERFORMED TO ASSESS YOUR SPECIFIC CONDITIONS, YOUR OVERALL HEALTH AND IN PARTICULAR YOUR SPINAL HEALTH. THESE PROCEDURES WILL ASSIST US IN DETERMINING IF CHIROPRACTIC CARE IS NEEDED, OR IF ANY FURTHER EXAMINATIONS OR STUDIES ARE NEEDED. IN ADDITION, THEY WILL HELP US DETERMINE IF THERE IS ANY REASON TO MODIFY YOUR CARE OR PROVIDE YOU WITH A REFERRAL TO ANOTHER HEALTH CARE PROVIDER. ALL RELEVANT FINDINGS WILL BE REPORTED TO YOU ALONG WITH A CARE PLAN PRIOR TO BEGINNING CARE.

I UNDERSTAND AND ACCEPT THAT THERE ARE RISKS ASSOCIATED WITH CHIROPRACTIC CARE AND GIVE CONSENT TO THE EXAMINATION THAT THE DOCTOR DEEMS NECESSARY AND THE CHIROPRACTIC CARE, INCLUDING SPINAL ADJUSTMENTS, AS REPORTED FOLLOWING MY ASSESSMENT.

I AUTHORIZE DR. SHIQUITA WHITE AND ANY AND ALL GOD FAMILY CHIROPRACTIC STAFF TO PERFORM DIAGNOSTIC PROCEDURES, RADIOGRAPHIC EVALUATIONS, RENDER CHIROPRACTIC CARE AND PERFORM CHIROPRACTIC ADJUSTMENTS TO MY MINOR/CHILD.

AS OF THIS DATE, I HAVE THE LEGAL RIGHT TO SELECT AND AUTHORIZE HEALTH CARE SERVICES FOR MY MINOR/CHILD. IF MY AUTHORITY TO SELECT AND AUTHORIZE CARE IS REVOKED OR ALTERED, I WILL IMMEDIATELY NOTIFY GOD FAMILY CHIROPRACTIC.
Name

First NameLast Name
Today's date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Address

New Practice Member Intake