Back to Life Chiropractic
Dr. Brian H. Wikoff
2431 N. Tustin Ave. Suite A
Santa Ana, CA 92705

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.)


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?

Insurance & Payment for Care

Primary Insurance
Secondary Insurance

If an auto accident, please provide:

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?

Reason for this Visit

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

Does this concern interfere with:


For Women Only


Health Problems & Concerns:

Please select all that you have had or currently have.

Auto Accident

Visited a Hospital or Doctor?

Were you rendered unconscious?
Traffic violation issued?
Retained an attorney?

In relation to the base of your skull, where was the headrest?

Impact to your vehicle came from?

The direction you were heading?
The direction they were heading?

The direction you were facing?
What did your vehicle impact?

Strike anything in the vehicle?

Describe the accident?

How did you feel right after?

Names of all persons in this accident:


I certify that I'm the patient or legal guardian of the patient listed above. I give authorization to treat myself,or if patient is a minor,consent to treatment. I have read and understand the questions above and they are true to the best of my knowledge. I consent to the collection and use of the above information for this office. I hereby authorize the office to release all information necessary to any insurance company, attorney, or other for the purpose of claim reimbursement of charges incurred by me. I grant the use of my signed statement of authorization with my signature for required insurance submissions. I agree that all services rendered to me will be my responsibility. I will provide prompt payment of such services. I understand and agree that health/accident insurance policies are an arrangement between an insurance carrier and myself and will provide prompt payment. Payment of services will become immediately due upon suspension or termination of my care. I hereby request and consent to the performance of chiropractic adjustments, chiropractic procedures and examinations, physiotherapy, and diagnostic x-rays on me or patient named above for whom I am legally responsible by the doctor, associate, or student intern, affiliated with Wikoff Chiropractic Inc., DBA Back to Life Family Chiropractic. I understand that, as in the practice of medicine, in the practice of chiropractic care there are some risks to treatment, including but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications. I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based on the facts then known, is in my best interests. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment. I give authorization to the doctor and his/her staff to use photographs and testimonials for advertising purposes. I have the right to refuse and will submit the request in writing and it will be kept in my records. By signing below I agree with all of the above.

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


Finalizing Form

  1. Submit Form!