File opening Cliquez ici pour la version française Patient Date Time Rejected Send Email Paragraph 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 No 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 No Please indicate your preferences for an appointment. Morning-10:00-13:00 Afternoon-13:30-16:30 Evening-17:00-21:00 If you are human, leave this field blank. Submit
