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  • New Chiropractic Pediatric Intake

    Please complete this form prior at least 24 hours prior to your appointment. Feel free to call if you have problems with this form 919-322-4383. We look forward to seeing you soon!
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  • Health insurance policy information

    Please complete this section entirely. If you are self pay (do not participate with a health insurance plan) please select self pay and move to the next section.

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  • Prenatal History

    Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.
  • Birth History

    Please complete the following fields to the best of your ability. This information will help us with your case and should not be left blank.



  • Baby/Toddler (0-4)

    Please complete the following fields to the best of your ability if your child is within this age range. This information will help us with your case and should not be left blank.
  • Child (5-12)

    Please complete the following fields to the best of your ability if your child is within this age range. This information will help us with your case and should not be left blank.

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  • You're done! Thank you for completing this form, click 'Submit' below and we'll receive your information. We look forward to helping you life life well! 

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