Please complete the paperwork below prior to your visit.
This will decrease your wait time. Thank you.

Personal

Address(Required)
Date of Birth(Required)
Gender(Required)

Emergency Contact

Date of Birth(Required)
Relationship(Required)

Questionnaire

How Often?(Required)
0 is no pain, 10 is unbearable pain
Is it getting better or getting worse?
In general, when is it the worst?(Required)
Was your previous chiropractic experience positive?
Was your previous physician/therapist experience positive?
Do you smoke?

Health History

Please select all that apply(Required)
Authorization(Required)
Photo/Video Consent(Required)

Informed Consent to Chiropractic Treatment

Consent to Chiropractic Treatment(Required)

Please Sign below when you arrive at our office.

Printed Name of Patient:




Signature of Patient:




Signature of Minor:




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