File opening Cliquez ici pour la version française Patient Administration Active Follow-up Date Appt Date Follow-up … .. Imaging MRI X-ray Need Done Media Report CD Need Done Source Public Private Insurance Yes No Prescription Needs from DC from MD Rx needed No Rx Needed Booked & Called Called Appt Booked LM email remninder First Name * Last Name * Gender * Male Female Address * City * Postal Code * Cell Phone Home Phone Work Phone Email * Profession Date of Birth * Briefly describe your condition. * Do you have medical imaging? MRI CT-scan X-ray none Do you authorize the clinic to communicate with you by email? * Yes No I hereby authorize the chiropractor to perform the examinations he deems necessary for the opening of my file. Some patients may experience aches or slight worsening of symptoms following the exam. These symptoms are generally of short duration, but it is important to mention them to the chiropractor at your next visit. * Yes No Please indicate your preferences for an appointment. Morning-10:00-13:00 Afternoon-13:30-16:30 Evening-17:00-21:00 Submit If you are human, leave this field blank.
