Consultation Admittance Form

Chiropractic Care

Health History Questionnaire

Have you ever been diagnosed or told you to have any of the following?

Missed appointments are an inconvenience not only to us but also for other patients who may have wanted your appointment time. If you do not call to inform us that you cannot keep your scheduled appointment you will be billed.

I understand that my Supplemental Health Care coverage for chiropractic care represents only a portion of the Doctor's fee and that I am personally responsible for the balance of that fee.