New Customer Step 1: Intake form Name* First Last Suffix Nickname (Optional)Email* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Sex*MaleFemaleAge*Date Of Birth* Date Format: MM slash DD slash YYYY Marital Status*SingleMarriedWidowedOccupation*Employer*Home Phone*Work Phone*Best Time To Reach You*MorningLunchAfternoonEveningSurgical History (If Applicable)DependentsDependent(s) 18 and Older Name Sex Date Of Birth Actions Edit Delete There are no Dependents (18 and older). Add Dependent (18 and older) Maximum number of dependents (18 and older) reached. Dependent(s) Under 18 Name Sex Date of Birth Actions Edit Delete There are no Dependents (Under 18). Add Dependent (Under 18) Maximum number of dependents (under 18) reached. Emergency ContactName* First Last Relationship*Work Phone*Additional InformationHow did you hear about us?*Word of Mouth (Family / Friend)Online (Google Search / Advertisement)Social Media (Facebook / Instagram)PodcastPrefer Not To SayWho may I thank for referring you? (Optional)Chiropractic Terms Of AcceptanceWhen a person seeks chiropractic care and that person is accepted for such care, it is essential for the chiropractor and patient/practice member to be working toward the same goal. Chiropractic care has only one objective: remove nerve interference to allow the body to fully express life. It is important that each person involved understand both the objective and the method used to attain it. This will prevent any confusion or disappointment. The following Definitions will help you understand the objective of your Chiropractor. Chiropractic Adjustment: A Chiropractic adjustment is a method of specific application of forces to the spine to facilitate the body's correction of vertebral subluxation. Health: A state of optimal phy sical, mental, and social well-being, not merely the absence of disease or infirmity. Our ultimate goal is to increase your body's expression of life (health) by correcting vertebral subluxation. Vertebral Subluxation: A misalignment of one or more of the 24 vertebra in the spinal column which causes an alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate (natural) ability to express its maximum health potential. We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider that specializes in that area. Regardless of what the disease or condition is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY OBJECTIVE is to eliminate major interference to the expression of the body's innate, or inborn, intelligence. Our only method is specific adjusting to correct vertebral subluxation.Consent* I have read and fully understand the above statements. The information I have provided above is true to the best of my knowledge. I hereby consent to chiropractic care and authorize Dr. Lee Grant to provide chiropractic services. NO GUARANTEE NOR ASSURANCE HAS BEEN MADE TO ME concerning results of the procedures.
