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100 Year Lifestyle Chiropractor in Dunwoody GA
Phone: 770-391-2771
Make Your Health a Priority!

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Patient Forms

Consultation History

Please print and complete this form when coming in for a consultation with Dr. Wallin



New Patient Questionnaire

Please complete questionnaire prior to new patient



Initial Health Intake Form

Health Intake Form



2018 Clinic Policies

Please read through our office policies. Sign and date once you have read and understood the policies as they are stated.



Privacy Policies

Please sign stating that you understand and agree to our notice of privacy policies.



Medical Authorization/Release

This form is for future use in case you ever need us to forward any of your records on your behalf. Please fill out the top of this form. Mark all that you are comfortable with us sending. Leave the "send to" portion blank so that we may fill it in as needed and sign at the bottom.



Informed Consent (Adult)

Please sign stating that you understand what chiropractic care is and consent to our treatment.



Participation Policies

This form states what you, as a patient, should expect during each visit with us, and what we, as your provider, expect of you as our patient. Please read and initial next to each statement and then sign the second page.



Electronic Health Records Intake

Please fill out demographic information and let us know any allergies you may have and any medications your are currently taking.



Terms of Acceptance

Please sign stating you understand that we treat certain ailments in our clinic using specific chiropractic methods.



Personal Injury Information

Personal Injury Patients ONLY. Please fill in with all applicable information. You must have a bodily injury claim number or attorney representation prior to treatment. Please provide all of the information listed at the bottom when you come in for your appointment. *the lien will be signed once you arrive*



Personal Injury Financial Policy

For Personal Injury Patients ONLY.
Please read thoroughly and sign stating that you understand and agree to the terms.
Please provide the applicable proof of insurance listed at the bottom of the page when you come in for your appointment.



Accident History Questionnaire

This form is to be used ONLY when coming in for a personal injury case. Please fill out this form in its entirety prior to coming in for your new patient appointment.



Minor Consent

If patient is under the age of 18 please sign confirming your consent to treat. Additional minor paperwork will be provided upon arrival in the office.



Developmental Milestones

For all Pediatric patients.
Please complete the form in it's entirety to the best of your ability.



Pediatric 0-9

For new patients aged newborn - 9 years old.
Please complete the form in it's entirety to the best of your ability.



Pediatric 10-17

For new patients aged 10-17.
Please complete the form in it's entirety to the best of your ability.