Vert Chiropractic
MOVEMENT NOURISHMENT LIFESTYLE
4444 Lacey Blvd Lacey Washington
360-999-9848
There is no better time then NOW to achieve your wellness g
o
als!
NEW PATIENT OFFER
Name
(required)
Email
(required)
Phone Number
(required)
Address
(required)
City & State
(required)
Zip Code
(required)
Date of Birth
(required)
Social Security Number
(required)
Height
(required)
Weight
(required)
Previous Surgeries or Hospitalization (if none, write "none")
(required)
How did you hear about us?
Search Engine
Social Media
TV
Friend or Family
Health History:
(required)
Asthma
Allergies
Heart Disease
Stroke
Diabetes
Anorexia
Alcoholism
Anemia
Arteriosclerosis
Arthritis
Breast Lump
Bloating
Bruise Easily
Cancer
Chest Pain
Cold Extremities
Menstrual Issues
Constipation
Concussion
Seizures
Auto Immune Disease
Digestive Problems
Dizziness
Eating Disorder
Eye Pain or Difficulties
Joint Replacement
Hemorrhoids
Frequent Urination
Fatigue
Hot Flashes
Irregular Heart Beat
Kidney Infection/Stones
Loss of Memory
Loss of Balance
Loss of Smell
Loss of Taste
Loss of Hearing
Nausea
Faint
NONE OF THESE ABOVE
Primary Area of Discomfort:
(required)
Please describe the pain at worse (worse at night, in the morning): Level of Pain (0 being no pain 10 being worse pain ever)
What does the discomfort prevent you from doing (health, home, hobbies):
By submitting your information. you hereby request and consent to the performance of chiropractic adjustments and other chiropractic procedures, including various modes of physical therapy and diagnostic x-rays, on me (or the patient named below, for whom I am legally responsible) by the doctor of chiropractic named below and/or other licensed doctors of chiropractic who now or in the future treat me while employed by, working or associated with or serving as back-up for the doctor of chiropractic named below, including those working at the clinic or office listed below or any other office or clinic. I have had the opportunity to discuss with the doctor of chiropractic named below and/or with other office or clinic personnel the nature and purpose of chiropractic adjustments and other procedures. I understand and I am informed that, as in the practice of medicine, in the practice of chiropractic there are some risks to treatment, including, but not limited to, fractures, disc injuries, strokes, dislocations and sprains. I do not expect the doctor to be able to anticipate and explain all risks and complications, and I wish to rely on the doctor to exercise judgment during the course of the procedure which the doctor feels at the time, based upon the facts known, is my best interest. If any doctor(s) in this business prescribe needed x-rays with patient denial the business has right to refer patient to another doctor. I have read, and or have had read to me, the above consent. I have also had an opportunity to ask questions about its content, and by signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition (s) for which I seek treatment.
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