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Patient Intake Form

Contact Details

How did you hear about us? *
Address *

Contraindications For ARP:

Are you pregnant? *
Any pacemaker or ICD? *
Any history of blood clots? *

Present Condition

0-1: Pain | 2-3: Mild Pain | 4-5: Moderate Pain | 6-7: Severe Pain | 8-9: Very Intense Pain | 10: Worst Possible Pain
What treatments have you done? *
Check all that apply
What does your pain feel like? *
Check all that apply

Medical History

Do you have any medical records that have been created regarding your symptoms you are being seen for today? *

Diagnostic Tests

Have you had any diagnostic tests performed? *
Check all that apply

Truthful Representation

By initialing the following the following statement "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell the doctor when possible so it can be added to my record.
Your Initials


I understand while Dr. Earley and her staff agree to treat me, she cannot personally guarantee any results. I understand I will be advised of advantages and complications, if any, as well as other treatment options should they become necessary.
Your Initials

Release of Liability

In conjunction with my ARP Wave treatment at Huebner Chiropractic and Neuro Sports Performance & Rehab, as part of the consideration for my treatment, I, my heirs, executors, spouse, assigns, offspring, agents and representatives expressly release, hold harmless and indemnify Huebner Chiropractic/Neuro Sports Performance & Rehab owners, agents, employees, representatives, assignees, and licensees from all liability for any treatments given.
Your Initials

Consent to Treatment

By signing below, I hereby give my consent to treatment.
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