It is our pleasure to welcome you to our family of happy and healthy chiropractic members. Please let us know if there is any way we can make you and your family feel more comfortable. Many types of stressors (physical, mental and chemical) can interfere with your child’s growing brain, spine and nervous system. To help us serve you better, please complete the following history information about your child. We look forward to working with you to build a better future for your family.

Please provide us all details to help us better serve you and your child.

Your child’s spine is vulnerable to stress and should routinely be checked by a Doctor of Chiropractic for prevention and early detection of Vertebral Subluxation (spinal nerve interference). Spinal nerve interference can affect the following: (check any of the following milestones that your child has/had delays or difficulties meeting)

According to the National Safety Council, approximately 50% children fall head-first from a high place during their first year of life (i.e. bed, changing table, stairs).

This form is to assist the doctors by providing family history information for their review.

We love sharing pictures of the healthy children of Kauri Chiropractic! If you would allow us to take, use, and share your child’s photograph and/or testimonial/comments, please sign below. For valuable consideration, I hereby irrevocably consent to and authorize the use for the purposes of marketing and promotion by Kauri Chiropractic, or anyone authorized by Kauri Chiropractic, of any and all photographs/videos which we taken of myself and my child, which may include, but are not limited to promotional materials such as social media, website, and/or print ad whatsoever, for an indefinite period of time without further compensation to me. All media shall constitute the property of Kauri Chiropractic, solely and completely. Any information voluntarily provided by a practice member shall also be used in conjunction with the above information for the purposes previously mentioned. Confidentiality, in regards to any reported conditions, is also waived to the extent of information pertinent to the promotion material only. All other unrelated practice member information shall remain private and protected (according to the Health Information Act).

I authorize the Doctor and any and all Kauri Chiropractic Staff to perform consultation, diagnostic procedures, radiographic evaluations, render chiropractic care, and perform chiropractic adjustments to my child/minor, according to their respective qualifications. As of this date, I have the legal right to select and authorize healthcare services for my child/minor. If my authority to select and authorize care is revoked or altered, I will immediately notify Kauri Chiropractic.