File opening | Sicotte DC

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Patient

If you are human, leave this field blank.

Date

Time

First Name *

Last Name *

Address *

City *

Postal Code *

Home Phone

Work Phone

Extension

Cell Phone

Email *

Do you authorize the clinic to communicate with you by email? *

Yes

Profession

Gender *

Male

Female

Date of Birth *

Briefly describe your condition. *

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