For client convenience our intake forms are available online to print and complete. Please complete all forms legibly in ink. Fax completed forms to us at (913) 962-7416 along with a copy of the front and back o your insurance card and bring the original paperwork with you to your appointment. We request new clients arrive 10 minutes prior to their scheduled appointment time to allow our staff time to review paperwork.
If you choose not to download forms and instead complete them at the Center, please arrive 30 minutes prior to your scheduled appointment time.
Please call us at (913) 962-7408 if you have questions regarding completion of forms. Thank you for trusting us to care for your wellness.
Click here for information on our Financial Relationship
Adult Forms – Age 11 years and older
Chiropractic
• Adult Intake Paperwork
• Chiropractic Informed Consent
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
• Medical Records Release
(Complete this form if you choose to forward x-rays or MRI reports to Your Wellness Connection for review.)
Massage
• Adult Intake Paperwork
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
Acupuncture
• Adult Intake Paperwork
• Acupuncture Informed Consent
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
Counseling
• Adult Intake Paperwork
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
Functional Medicine
• Adult Intake Paperwork
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
• Medical Records Release
(Complete this form if you choose to forward lab work to Your Wellness Connection for review.)
Pediatric Forms – Age 10 years and younger
• Pediatric Intake Paperwork
• Chiropractic Informed Consent
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
Auto Accidents
Existing clients complete only the Automobile Accident Questionnaire and Lien and Payment Authorization.
• Adult Intake Paperwork
• Chiropractic Informed Consent
• Patient Privacy Policy – HIPAA
• Financial Relationship Form
• Automobile Accident Questionnaire
• Lien and Payment Authorization
Existing Client Misc. Forms
Metabolic Assessment Form
Medical Records Release
