Web Intake Form

If you are a new patient we ask that you fill out an intake form. Thank you in advance!

***please ensure that you input the verification code at bottom of form and hit the submit button***

(see that this code is processed – you should receive an email as confirmation with the information that you have input below in the form)

New Patient Intake Form   Dr. Erika Kneeland, ND


Please list any operations, hospitalizations, childbirths, major accidents or traumas you have had:

Please indicate below which of the following conditions have affected your relatives:  Indicate: F-Father, M=Mother, S1=Sibling, S2=Sibling etc., PGM=Paternal Grandmother, MGM=Maternal Grandmother, PGF=Paternal Grandfather, MGF=Maternal Grandfather, PA-Paternal Aunt, MA Maternal Aunt, PU=Paternal Uncle, MU=Maternal Uncle