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Chiropractic Intake Forms

Adult Intake Form – Pembroke

Adult Intake Form – Lakeside

Adult Intake Form – 125

Pediatric Intake Form – All Offices

The Lifestyle Center at Crossroads

CranioSacral Therapy Intake Form

Diet Diary

Orthotics Questionnaire

Request X Rays

X Ray Request Form
This form is used to request your x-rays or records from a hospital or doctor’s office. Bring this completed form to our office and we will fill in the rest of the information and submit it to your provider.

X Ray Release Form
This form will authorize Crossroads Chiropractic to release your x-rays to you or to another provider.  Please fill out the form completely, and sign and date at the bottom.  You may fax, email, or bring in the form to our office.  Any copy fees must be paid before your records can be released.  Most records will be ready for pickup in 24 – 48 hours.