For New and Existing Patients
Many of the following conditions respond to chiropractic treatment.
Are you CURRENTLY experiencing any of these symptoms? (Please select all that apply and us comments to elaborate)
In order you properly assess your condition, we must understand how much your condition has affected your ability to manage everyday activities.
For each item below, please select the number which most closely describes our condition right now.
Have you EVER had any of the following? (Please select all that apply and use comments to elaborate)
Please select all that apply and use comments to elaborate.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2023 Hush Communications Canada Inc.