NEW PATIENT FORM


When a patient seeks chiropractic health care and we accept a patient for such care, it is essential for both to be working towards the same objective.  Chiropractic has only one goal. It is important that each patient understand both the objective and the method that will be used to attain it. This will prevent any confusion or disappointment. 

Adjustment: An adjustment is the specific application of forces to facilitate the body's correction of vertebral subluxation. Our chiropractic method of correction is by specific adjustments of the spine. 

Health: A state of optimal physical, mental and social well-being, not merely the absence of disease or infirmity. 

Vertebral Subluxation: A misalignment of one or more of the 24 vertebrae in the spinal column which causes alteration of nerve function and interference to the transmission of mental impulses, resulting in a lessening of the body's innate ability to express its maximum health potential. 

We do not offer to diagnose or treat any disease or condition other than vertebral subluxation. However, if during the course of a chiropractic spinal examination, we encounter non-chiropractic or unusual findings, we will advise you. If you desire advice, diagnosis or treatment for those findings, we will recommend that you seek the services of a health care provider who specializes in that area. 

Regardless of what the disease is called, we do not offer to treat it. Nor do we offer advice regarding treatment prescribed by others. OUR ONLY PRACTICE OBJECTIVE is to eliminate a major interference to the expression of the body's innate wisdom. Our only method is specific adjusting to correct vertebral subluxations. 

By submitting the form below, you are agreeing that you have read and fully understand the above statements, and are submitting an honest medical history, and that all questions regarding the doctor's objectives pertaining to my care in this office have been answered to my complete satisfaction.


Please take your time and fill out the information below.  On submitting, you can walk-in or you will be prompted to schedule your appointment - either is fine!  

Patient Info
Name *
Name
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Date of Birth *
Date of Birth
Family Info
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Medical History
What type of pain is it? *
Do you have a history of any of the following? *
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If you checked any of the boxes above, please describe further here
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Are you currently on any medications? *
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Did you have any medical conditions in the past (epilepsy, asthma, etc.)? *
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