Patient Forms

Thank you for bringing Summit Vitality onto your health care team! Below you will find all the forms you will need for your first visit. Please download, fill them out, and bring with you to the visit.

First Visit Check List

- Adult or Child intake form
- HIPPA Form
- 7 day health diary - you will not need to fill this out yet
- Policy Forms

Pediatric Intake Form

Required for new patients under 18 years of age.

Adult Intake Form

Required for new patient 18 and older.

Privacy Policies (HIPPA)

Required for all new patients.

7 Day Health Diary

Required for new patient visits, useful for anyone!


Required for new patients and guardians.

  • White Facebook Icon
  • White Twitter Icon
  • White Instagram Icon
  • White LinkedIn Icon
  • White YouTube Icon

(704) 765-0887

©2015 - 2020 Summit Vitality, LLC. All Rights Reserved.

This content is for informational and educational purposes only. It is not intended to provide medical advice or to take the place of such advice or treatment from a personal physician. All readers of this content are advised to consult their doctors or qualified health professionals regarding specific health questions. Neither Summit Vitality nor the publisher of this content takes responsibility for possible health consequences of any person or persons reading or following the information in this educational content. All viewers of this content should consult their physicians before beginning any nutrition, supplement or lifestyle program.