This form gives us an overview of pre-existing conditions. Please highlight or check off anything that applies to you
This form provides us with more context and information about the condition you are experiencing, as well as prior conditions that have affected you
This form provides us with your personal information
This form gives us a visualization of the pain you are experiencing. Please draw anything that applies to you directly on the diagram (in the locations that pertain to your condition). If you experience pain in multiple areas of the body and the pain levels differ depending on the area, you can make note of this by writing the number near the area
Sign this form to provide us with consent to chiropractic treatment
Forms and Paperwork
If you have any questions about how to fill out these forms, call or email us.
If there are any technical limitations that may prevent you from filling in and submitting these forms digitally, please let us know. Paper copies of the forms will be provided for you to fill out in your vehicle before the appointment. You will need to arrive earlier than your scheduled appointment time to ensure that all paperwork is filled out.
Please fill out the following digital forms before your first appointment.
Note: You may be required to click "Enable Editing" before you are able to make changes to the forms
Email completed forms to: email@example.com
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Back In Action Chiropractic and Rehabilitation