[HEALTH] Chiropractic Clinic New Patient Intake Form

At [ENTER NAME OF ORGANIZATION], providing tailored care and treatment for our patients is priority. In order to fulfill our objectives, we require as much information as possible from each patient. Thank you in advance.

[ENTER ORGANIZATION NAME, ADDRESS]
Phone: (123) 456-6789
Email: YourName@YourEmail.com
Website: YourWebsite.com

1Personal > 2Health Concerns
Welcome to our Clinic!
Our Location
PERSONAL INFORMATION

Please complete the following
Your Name * First Last
Date of birth *
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Age *
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Sex *
Male Femaile
Address *
Address Type Street Address Address Line 2 Apartment City State / Province / Region Postal / Zip Code Country
Home phone * - ### - ### ####
Cell phone - ### - ### ####
Business phone - ### - ### ####
Email Address
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Confirm Email *
Social Insurance Number (if this is a WSIB claim)
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Marital Status *
Single Married Common law Divorced Widowed
Do you have children? If so, how many?
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Occupation *
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Employer *
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Have you visited a chiropractor before? *
Yes No
If yes, name of previous chiropractor?
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If yes, when was your last visit?
less than 1 week ago 2 weeks ago 1 month ago 2-3 months ago 4-6 months ago 6-12 months ago over 12 months ago
If yes, what were the results?
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Name of family doctor? (if you have one)
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Family doctor phone - ### - ### ####
How did you learn about our clinic? *
Newspaper Internet Print flyer Yellow Page Building sign Referral's name:
AUTHORIZATION FOR CARE OF A MINOR (UNDER 16 YEARS)

Please ONLY complete the following if the patient is under 16 years of age
Parent or Guardian 1 name First Last
Parent or Guardian 1 phone - ### - ### ####
Parent or Guardian 2 name First Last
Parent or Guardian 2 phone - ### - ### ####
I hereby authorize and consent to the chiropractic evaluation and care of my child.

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[HEALTH] Chiropractic Clinic New Patient Intake Form

[HEALTH] Chiropractic Clinic New Patient Intake Form

PERSONAL INFORMATION

AUTHORIZATION FOR CARE OF A MINOR (UNDER 16 YEARS)