New Patient Intake Form

How It Works

Three simple steps — and you're ready for your first visit.

Step 1

Fill Out the Form

Answer the health questions below. It takes about 10–15 minutes and works on any phone, tablet, or computer.

Step 2

Submit Securely

Your answers are sent directly and confidentially to our clinic — HIPAA compliant and never shared.

Step 3

Arrive Ready

Dr. Bantique reviews your history before you arrive, so your first visit focuses on you — not paperwork.

Already a patient? Just call us at (916) 483-3423

New Patient Paperwork

Complete Your Intake Form

Please complete this form before your first visit so we can review your history ahead of time — and get straight to helping you feel better.

Before you begin, have this ready:

Your contact and address details
Your primary care doctor's name
A list of medications you take
Any past surgeries or imaging

Fields marked with * are required. Your answers save only when you press Submit.

Secure & Confidential

HIPAA Compliant - Your information is protected

Initial Health Status

Patient Information

Patient Name *

Birthdate *

Address *

City

State

Zip

Email

Phone

Gender *

M F

Occupation

Employer

Work Phone

Emergency Contact

Emergency Contact (Name)

Emergency Contact Phone

Physician Information

Primary Care Physician Name

PCP Phone

Previous Chiropractor Name

Previous Chiropractor Phone

Describe Your Current Problem and How It Began

Imaging

Have you had spinal X-rays, MRI, or CT scan for your area(s) of complaint?

No Yes

Date(s) Taken

What Areas Were Taken?

Medical History

Please check all of the following that apply to you:

Surgeries

Stroke (Date)

Cancer/Tumor (Explain)

Currently Pregnant – Number of Weeks

Family History

Cancer Heart Problems/Stroke Diabetes Rheumatoid Arthritis High Blood Pressure Blood Clots / DVT

Tobacco Use & Medications

Tobacco Use – Type

Tobacco Use – Frequency (per day)

Medications

Consent & Acknowledgment

I certify to the best of my knowledge, the above information is complete and accurate. I agree to notify this practitioner immediately whenever I have changes in my health condition. I understand that my chiropractor may need to contact my physician if my condition needs to be co-managed. Therefore I give authorization to my chiropractor to contact my physician, if necessary.

I agree to the above statement. *

Patient Signature

Date

By submitting this form, you agree to our Terms of Service and Privacy Policy

Need Help with the Form?

If you have questions or need assistance, please call us at (916) 483-3423 or email info@bantiquechiro.com

Need Assistance?