Intake Form

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Emergency Contact

Emergency Phone

Relationship

Google

Facebook

Youtube

From a friend/family/another patient

Other

Insurer

Policy Name

Policy / Group / Plan #

Member ID / Certificate #

Policy Holder

I'm not the policy holder.

First Name

Last Name

Relationship To Patient

Date of Birth

Address

City

Prov / State

Postal / Zip Code

Phone Number

Is this injury as a result of a Motor Vehicle Accident?

Yes

If yes, what is the date of the Motor Vehicle Accident?

What do you believe is wrong with you?

Characters: 0/255

Please list any heath care professionals you have seen in the past?

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Have you ever had Chiropractic Treatment before?

Yes

If yes how long has it been since your last treatment?

Characters: 0/255

If yes, how many cigarettes do you smoke per day?

Characters: 0/255

If yes, how many drinks do you have per week?

Characters: 0/255

If yes, how many hours do your exercise per week?

Characters: 0/255

Females Only, if you are pregnant, how many weeks are you pregnant?

Characters: 0/255

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