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Name (First Name, Last Name)
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Nickname
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Social Security #
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Date of Birth (mm-dd-yyyy)
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Address (Street Address, City, State / Province, Postal / Zip Code)
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Phone Number
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Email (By entering your email address, you are consenting to receiving emails from Chiropractic Connection)
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May we send you text reminders?
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How did you hear about our office?
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What is your occupation? (Please include name of employer.)
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Tell us about your health concerns:
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What area are you interested in having laser performed on?
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Please list surgeries, traumas and any auto accidents here
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Please provide a list of Medications here (if any)
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Do you have a history of cancer? If so, please identify location
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How would you rate your pain currently (Scale of 0-10; 10 being the worst pain you've experienced.)
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How long has this been occurring?
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Are you currently on any medication with light/heat sensitivity? (If "yes", usage of this laser device is not advised and we will not be able to proceed.)
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Do you have a pacemaker?
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By signing this form, you understand that this service is not billable toward insurance.
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Signature
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Date Signed (mm-dd-yyyy)
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