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Name (First Name, Last Name)
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Today's Date (mm/dd/yyyy)
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What condition originally brought you to our office? (Please list only one)
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Current improvement of condition scale:
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What other condition brought you to our office? (Please list only one (if applicable))
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Current improvement of condition scale:
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What other condition brought you to our office? (Please list only one (if applicable))
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Current improvement of condition scale:
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Which health gains have you experienced since you began chiropractic care?
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We would love to hear your opinions/comments regarding your experience in our office so far:
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Your doctor will record a video of them reviewing your posture and send it to you in an e-mail within 48 hours. This way, you can watch on your own time and ask any questions at your next appointment!
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If you are on a monthly plan- this fee is included in your payment. If you are utilizing your insurance and/or paying each time you come, there is an additional $55 fee.
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This fee is not reimbursable by insurance. The fee covers your posture analysis as well as your review.
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Signature
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Date Signed (mm-dd-yyyy)
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