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Pediatric Chiropractic Intake Form

Patient (Child) Information

General Questions/Prenatal History

Feeding History

Childhood Diseases

Developmental History

During the following times your child's spine is the most vulnerable to stress and should routinely be checked by a Doctor of Chiropractic for prevention and early detection of vertebral subluxation (spinal nerve interference). At what age was your child able to:

Review of Systems


Authorization to Treat a Minor

I agree as the undersigning parent/guardian having legal custody/guardianship of the above mention minor, do hereby authorize, request and direct Dr. Thompson and whomever she might designate as assistant to perform in judgment any examination and chiropractic diagnosis or treatment which is deemed necessary. Any specific written authorization you provide may be revoked at any time by writing to us at the address provided on the front of this form.

THIS ---->https://touchoflifechiro.com/new-patient-center/pediatric-chiropractic-intake-form.html

Office Hours

Monday9-13 - 6
TuesdayClosed3 - 6
Wednesday9 - 13 - 6
Friday9 - 1closed
SaturdayBy AppointmentClosed
Day Morning Afternoon
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
9-1 Closed 9 - 1 Closed 9 - 1 By Appointment Closed
3 - 6 3 - 6 3 - 6 Closed closed Closed Closed


Dr. Patrice Thompson is hands down the best! With my husband having migraines she educated him on the benefits of chiropractic care, and was able to ease stress and pain stemming from his migraines. My husband and I can't wait to be adjusted again!! Thank you so much!

S. Dukes
East Point, GA

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