Roots Chiropractic

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 fill out all applicable information, if there is information not associated with your issue (including pediatric) Dr. Hegi will follow up with you on your visit. ****Filling out this information DOES NOT automatically schedule or issue an appointment request, please call us at 316-364-3128 to schedule****

Who are you?