Forms for Minor Patients - Ages Birth to 5

Gardiner Family Chiropractic offers our patient forms online so you can complete them in the convenience of your own home or office.

• If you do not already have AdobeReader® installed on your computer, Click Here to download.
• Print out all forms below and fill in the required information. We ask that you complete the forms as close to your appointment time as possible so that your doctor may have the most current information regarding your condition.
• Bring your completed forms with you to your appointment along with your driver's license and any insurance cards.

Registration Form - Required for all patients

Personal information about yourself. It must be filled out completely and must be signed and dated so that we may bill your insurance company directly.

Registration Form

Child History Form

A form spefically designed to gather health information about our youngest patients.

Child History Form

Notice of Privacy Practices - Required for all patients

This form explains our policies and your rights regarding our disclosure of your Protected Health Information. This form must be signed and dated before a file for you can be started in our office.

Notice of Privacy Practices

Consent to Treat a Minor

This form must be completed by the minor's parent/legal guardian before the child may be seen in our office.

Consent to Treat a Minor

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