Patient Forms

If you are new to the Wallpe Chiropractic & Wellness family, we can't wait to serve you! But first, we need a little more information so that we can provide you with the care you deserve. With our new health records system we are able to send these forms to you directly if you provide us with your email address at the time you schedule your appointment. If you do not have an email, please complete the appropriate Intake Form below, as well as the Patient Consent Form. Please bring printed copies with you at the time of your visit.

Downloadable Forms

Adult Intake Form

If you are a new adult patient, we can't wait to meet you! Please download the fillable PDF below and submit it via email or at your first visit. You may also print it and bring it to your first appointment.

Download

Pediatric Intake Form

If you are the parent or legal guardian of a youth patient, please complete the fillable PDF below and submit it via email or at your first appointment. You may also print it and bring it to your first appointment.

Download

Pregnancy Intake Form

If you're pregnant and in need of chiropractic care, we are excited to serve you! Please download the fillable PDF and submit it via email or at your first appointment. You may also print it and bring it to your first appointment.

Download

Patient Consent Form

The attached fillable PDF authorizes us to provide you with care and also outlines our HIPAA information as it relates to your care. Please complete the PDF and submit it with your intake form(s). We can't wait to serve you!

Download

Infrared Sauna Intake & Consent Form

All patients will be required to fill out this online form. Please contact the office for our staff to send this specific fillable document to you ahead of your Full-Spectrum Infrared Sauna session. We will not allow use of this unit unless this intake/consent is filled out!

SCHEDULE

Patient Forms

Downloadable Forms

Adult Intake Form

Pediatric Intake Form

Pregnancy Intake Form

Patient Consent Form

Infrared Sauna Intake & Consent Form

Take a step toward wellness.

Contact Us

Address

Contact

Hours