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Welcome to our office! Please fill this form out as thoroughly as you can!
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Name (First Name, Last Name)
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Birthdate (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 Address
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Next: Health History
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Have you previously seen a chiropractor?
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If so, for what reason did you last see them and when was it?
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Please describe your health status, including:
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Please list any supplements/medications you are taking:
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What is your reason for today's visit?
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Is there anything else you'd like for us to know?
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Next: Fee Agreement
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Vacationer Fee Structure
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Signature of consent to fees: (By signing, I fully understand the above fees/statements and give my consent.)
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