Pediatric Forms

Pediatric (0-18) Forms

Please fill out the form below prior to the first visit.

Tackett Chiropractic - Pediatric Intake

Please select the child's age range (Must Select to Continue):*
Please select one option



Pediatric History

Birth History

What was the third semester presentation?
What was the mode of delivery?
Was the child breastfed?
Was the child taking formula?
Is the child up to date on vaccinations?

Current History

Please list below the ages in which the child was able to:

Mode of onset:
How often does the pain occur?
Relation to other body systems:
Relieving Factors
Aggravating Factors:
Description of Pain:
Has the child been seen by another provider for these symptoms?
Has your child ever been treated for emergency care?
School status:
Is the child experiencing any pain?

Please mark or circle areas on the diagram where you experiencing pain, discomfort or are concerned about.

Draw over image
Has the child received any diagnostic testing?
If so, select the imaging done:
Please indicate if the child had/has any of the following:
Has the child ever suffered from the following traumas?

Family History

ABN Period Covering January 1, 2023 to December 31, 2023

I understand that I may be financially responsible for any charges incurred at this office, including co-pays, deductibles, and charges denied or not covered by my insurance company.

I realize my care may be subject to pre-certification by the insurance company and I accept any and all documentation submitted by Tackett Chiropractic for review for medical necessity and base their approval/denial upon this documentation. I understand that this office agrees to notify me as soon as possible if service is not covered and will notify me if my care is not covered by my insurance company. If a treatment plan is approved, this office will make me aware of the number of office visits allowed at the time frame of the certification. Initial visits may be denied, and this may be beyond the approval. These charges will be the patient's responsibility if denied by the insurance company.

This office may seek payment from you for any services your health insurance plan determines to be not medically necessary.

I have read and understand my obligations for payment for care in the absence of insurance coverage.

Patient Consent Form (HIPAA), Period Covering January 1, 2023 to December 31, 2023

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the health Insurance Portability and Accountability Act of 1996 (H.LP.A.A). I understand that by signing this consent, I authorize Tackett Chiropractic Center to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect by other healthcare providers involved in my treatment)
  • Obtaining payment from third party payers (e.g.) we will check your insurance policy regarding benefits, claims, and authorizations online or by telephone.

I have also been informed of and given the right to review and secure a copy of my Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under H.I.PLA.A. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact Tackett Chiropractic Center at any time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and obtaining insurance information online or my telephone from the insurance companies and health and health care operations. I understand that Tackett Chiropractic Center is not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with the restrictions.

Consent to Treat Minor

| (we), the undersigned, parent(s)/legal guardian(s)/person having legal custody of (name of minor), a minor, do hereby authorize(name of doctor known as the as agent(s) for the undersigned to consent to any x-ray, examination, and chiropractic diagnostic ortreatment, which is deemed advisable by a licensed chiropractor, be rendered under the general or special supervision of anylicensed chiropractor.
It is understood that this authorization is given in advance to any specific diagnosis or treatment being required but is given toprovide authority to the above described agent(s) to give specific consent to any and all such diagnosis and treatment withchiropractor, meeting the requirements of this authorization, and may exercise his/her best judgement, deemed advisable.This authorization shall remain effective until stated date unless sooner revolved in writing delivered to the agent(s) noted above.


Thank you for taking the time to fill out this form.


Find us on the map

Office Hours

Our Regular Schedule

Tackett Chiropractic


8:00 am - 12:00 pm

2:00 pm - 5:00 pm


8:00 am - 12:00 pm

2:00 pm - 6:00 pm


8:00 am - 12:00 pm

2:00 pm - 5:00 pm


9:00 am - 12:00 pm

2:00 pm - 6:00 pm


8:00 am - 12:00 pm