Bennett Chiropractic and Wellness Center

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Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speeding up your office visit and allowing us to better serve your healthcare needs. Please answer these questions; Have you or have you been exposed to someone who:Traveled outside Florida, the US, or traveled from New York, New Jersey or Connecticut in the past 14 days? Had a fever, cough, cold, or flu like symptoms in the past 14 days? To your knowledge, have you been in contact with anyone that is now quarantined or tested positive for COVID-19? If yes, wait 14 days to schedule.

Who are you?