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Open 7 Days a Week

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New Patient Intake Form

Please fill out the following form to help us understand your physical condition.

Full Name

Email Address

Phone

Date of Birth

Emergency Contact (Name and Phone Number)

Are you Medicare Eligible? *

Yes

No

Do you have a Health Savings Account (HSA) or Flexible Spending Account (FSA)? *

Yes

No

What is/are your pain area(s)? *

Back

Shoulder(s)

Headache/Migraine

Hip(s)

Sciatica

Knee

Ankle(s)

Arm(s)

Wrist(s)

Elbow(s)

How did you first hear about Uplift Chiropractic & Therapeutics?

If you were referred by someone please tell us who so we may thank them.

Thanks for submitting!

You can download NEW PATIENT INTAKE FORM here.

Uplift Chiropractic
& Therapeutics

Villages of Devinshire
13100 Deerfield Pkwy
Milton, GA 30004

© 2020 Uplift Chiropractic & Therapeutics

OFFICE HOURS

Monday, Wednesday, and Friday
Morning 8:00AM - 12:00PM
Afternoon 3:00PM - 7:00PM

Tuesday and Thursday
Morning 8:00AM - 12:00PM

Saturday and Sunday
Morning and afternoon appointments available

Flexible after-hours appointments available throughout the week

REQUEST APPOINTMENT

CALL or TEXT 770.756.0022

EMAIL

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