Vitalite Chiropractic

All new patients, please fill out the Patient Intake Form below. If you are a returning patient, please fill in any items that might have changed since your last visit, including insurance information. Remember to bring to the appointment your driver's license and insurance card. For your convenience, you can upload a copy of your driver’s license and insurance card in the form below.

Patient Intake Form

Patient Information

First Name

Last Name

Email

Address

City

State

Zip Code

Mobile Phone

Last 4 Digits of Social Security Number

Date of Birth

Gender

Race/Ethnic Group

Marital Status

Height

Weight

Occupation

Employer

Emergency Contact Name

Emergency Contact Phone

Primary Doctor Name

By providing the name of the doctor, I authorize the release of healthcare documents to them.

Primary Doctor Phone

Insurance

Primary Insurance Company Name

Primary Policy Number

Primary Group Number

Primary Insurance - Name of Policy Holder

Primary Insurance - Date of Birth of Policy Holder

Secondary Insurance Company Name