This form is to be filled out by patients being seen as a family. Please note that each family member must have the age-appropriate individual intake completed as well.

** Families that are seen together qualify for discounted services

This form is for all adult patients wishing to be by Dr. Becky, including prenatal patients.

** If you are being seen as a family, please complete this form for every adult family member that will be treated.

To be filled by parents or guardians of pediatric or infant patients based on age.

*If you are being seen as a family, please complete this form for every child that will be treated.

** Parents of patients under 12 months should complete the infant intake form.

To be filled out by a parent or guardian prior to any minor child coming in for treatment.

To be filled out by families prior to coming in for treatment.