Patient Information

Pediatric Patient Intake Form

Please complete the form below for your child prior to their first visit. Providing this information in advance helps us prepare a thorough care plan and makes your appointment as smooth as possible. All fields marked with an asterisk (*) are required.

If you have any questions before your visit, call us at (512) 858-9355 or stop by our office at 800 Hwy 290 W, Building F, Suite 500, Dripping Springs, TX 78620.

Parent / Guardian Information

First Name *

Last Name *

Email Address *

Phone Number *

Relationship to Child *

Home Address

Child's Information

Child's First Name *

Child's Last Name *

Date of Birth *

Sex

Child's Pediatrician / Primary Care Provider

Reason for Visit

Chief Complaint / Reason for Visit *

When did symptoms begin?

Birth History (delivery type, complications, etc.)

Previous Chiropractic or Medical Care for This Condition

Known Allergies (medications, foods, environmental)

Current Medications or Supplements

Additional Notes or Questions

Insurance Information

Insurance Provider

Policy / Member ID

Group Number

By submitting this form you confirm that the information provided is accurate to the best of your knowledge.

Office Contact & Location

Phone: (512) 858-9355
Address: 800 Hwy 290 W, Building F, Suite 500, Dripping Springs, TX 78620

If you prefer to complete paperwork in person, please arrive 15 minutes before your child's scheduled appointment time. Our front desk team is happy to assist.

Ready to schedule your child's first visit?

Call us at (512) 858-9355 — our team is here to answer your questions and get your little one on the path to better health.

Make an Appointment (512) 858-9355