Welcome to Chiropractic Children’s Healthcare

All information will be kept confidential.

Child's Details *
Child's Details
Address *
Address
Date of Birth *
Date of Birth
Gender
Parent/Guardian Details
Mother/Guardian Details *
Mother/Guardian Details
Father/Guardian Details
Father/Guardian Details
Maternal and Child Health Nurse Details
Address
Address
General Practitioner Details
GP Name
GP Name
Address
Address
Paediatrician Details
Paediatrician Name
Paediatrician Name
Address
Address
In most cases we will send a report to your Paediatrician, General Medical Practitioner, Maternal and Child Health Nurse or any other Health Care Provider involved in your child’s care to inform them. If you do not wish this to occur please discuss with your Paediatric Chiropractor
Referrer Information
Terms and Conditions (Please check to indicate you have read and accept these terms) *
Health Information (Please check to indicate you have read and accept these terms) *
Research Information (Please check your option) *
Data collected Chiropractic Children's Healthcare may be used for research purposes. All data, if used for this purpose, will be de-identified prior to public release to maintain your privacy. By signing this document, you agree to the collection, storage and use of health information for research purposes. If you do not wish to be a part of the research conducted by Chiropractic Children's Healthcare, you may choose to "opt-out" at any time. This will not influence any
Data collected Chiropractic Children's Healthcare may be used for research purposes. All data, if used for this purpose, will be de-identified prior to public release to maintain your privacy. By signing this document, you agree to the collection, storage and use of health information for research purposes. If you do not wish to be a part of the research conducted by Chiropractic Children's Healthcare, you may choose to "opt-out" at any time. This will not influence any of your child's treatment or management.