Optilife Chiropractic

Pediatric New Patient Intake Form

Welcome to the pediatric new patient  form.  Please fill out this form as completely as possible.  If you need help answering a question, leave it blank if it is NOT a required field, or call us at 813 926-9500. We will help you answer the necessary unanswered questions when you arrive at the office. 

Completing this form online will speed up your initial visit.  It will take 5-10 minutes to complete this form. Most insurance companies will not cover pediatric treatments unless a specific condition exists.  Choose the cash option to bypass the insurance questions.  Please speak with the doctor regarding insurance eligibility for pediatric adjustments.

The form can be completed on a mobile phone, but it is easier on a tablet or desktop.  All fields with an asterisk are required fields.

Thank You!