Destination Wellness Center

Patient Intake Form

Welcome to our online Patient Intake Form. Chiropractic Patients: Please fill out all sections of this form and make sure to sign it at the end. Nutrition & Acupuncture Patients: Please only complete the following sections and skip ahead to the end and sign: *Demographics *Height & Weight *Contact Information *Emergency Contact Information *Insurance (Nutrition Services are self pay only) *Referral Information

Who are you?