South Valley Chiropractic PC
834 E 9400 S
Sandy, UT 84094

Patient Intake Form

Welcome to our online Patient Intake Form. The information you fill in will be sent directly to our office, speed up your office visit, and will help us to better serve your healthcare needs. Please take a moment to completely fill out this form, and upon completion of all form categories click the [Submit] button at the bottom of this form.

For your protection and security; Navigating away from this form before clicking the [Submit] button will dismiss all completed form fields. Successful submission will redirect you to a confirmation page.

Patient Information

Personal Information
Contact Information
Feet Inches

(We will NOT share your email with any third party. We will only use your email to contact you in relation to your care with our practice.)


Draw Your Symptoms

Click on a crayon and draw on the body above to indicate your symptoms
Ache / Dull Sharp / Stabbing Numb / Tingling Pins & Needles Burning Throbbing Cramping Radiating Other Pains eraser eraser clear

How did you find out about our office?

Did you hear about our office from an advertisement?

If Yes, Where:

Did you hear about our office from a phone or professional directory?

If Yes, Where:

Employment Information

Current Symptoms

If Yes, Explain:

If yes:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Explain:

If Yes, Where?

Personal Health History

Family/Primary Physician

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Separate details with "," comma as shown above.

Personal Incident History:

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

If yes:
Did you get professional care/treatment?

Family Health History

Separate details with "," comma as shown above.

(Example: arthritis, cancer, diabetes, heart disease, kidney disease, high cholesterol, etc.)

Reason for this Visit

If you're only here for chiropractic wellness services please skip this section.

Does this concern interfere with:


Goals for Your Care

People see a chiropractor for a variety of reasons. Some go for relief of pain, some to correct the cause of pain and others for correction of whatever is malfunctioning in their body. Your doctor will weigh your needs and desires when recommending your care program. Please check the type of care desired so that we may be guided by your wishes whenever possible.

Health Problems & Concerns:

Please select all that you have had or currently have.

Electronic Health Record (EHR) Information

Preferred Language: Ethnicity:
Smoking Status: Smoking Start Date:
Type of Tobacco:
Have you tried to quit? How much tobacco do you use?
How long have you used tobacco?
Current Medications And Dosage:
Medication Name Dosage
Medication Allergies:
Medication Name Reaction Date Discovered


PATIENT PAYMENT POLICY The payment must provide verification of insurance at time of service or patient will be charged cash for services. Cash patients must pay at the time of service to receive a courtesy discount. No payment at time of service will result in full charge for services rendered. All visits will be paid in full at time of service.CONSENT TO TREAT AND RELEASEI understand that the treatment I received from Dr. Rosquist and his staff may require them to come in physical contact with my body in order to properly perform chiropractic manipulation, acupuncture, ultrasound and other treatment modalities. I also understand that some treatment modalities may cause me some physical discomfort during and/or following treatment or may invade my sense of privacy. I hereby voluntarily consent to Dr. Rosquist and his staffs providing me such treatment has judge necessary by them and release them from any and all liability for doing so except for damages caused to me by their gross neglect.ASSIGNMENT OF INSURANCE BENEFITS-RELEASE OF PRIVATE INFORMATIONI hereby assigned my right To Payment for Services Rendered from My Insurance Company to South Valley Chiropractic, Inc. I authorize them to act on my behalf to process claims with my insurance company and to receive payment for the treatments they perform. I further authorize Dr. Rosquist and his staff to release confidential medical information to my insurance company as needed to process the insurance claims.FINANCIAL TERMS AND PROMISED TO PAY i agree to pay for all services performed on my behalf by Dr. Rosquist and his staff. i understand that my insurance may not pay for all charges and i agree to promptly pay for all services rendered regardless of what amounts my insurance actually covers. i understand and agree that payment is due at the time of service is rendered.TERMSin the event that I do not pay for the services rendered on my behalf at a time of service, I agree to pay a finance charge on unpaid balance at the rate of 18% annual percentage rate. Should the services of a collection agency or attorney be required to enforce my payment obligation, I agree to pay an additional collection surcharge equal to 40% of my balance was all attorney fees and court costs incurred,

Name of the Insured:
(Please Print)
Patient's/Guardian's signature:


Finalizing Form

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