Questionnaire | Chiropractor In London, ON

Save and Continue Later

Emergency Contact Information
Emergency Contact Name*
First Last
Emergency Contact Phone Number*
Emergency Contact Address
Street Address City State / Province / Region ZIP / Postal Code Country
Do you have an alternate address?*
- Yes
- No
My Alternate Address Is:
- A Permanent Address
- A Temporary Address
- A Parent's Address
Alternate Address
Street Address City State / Province / Region ZIP / Postal Code Country

Save and Continue Later

Final Consent & Confirmation
I hereby authorize the doctors in this clinic to examine my condition and render care as deemed necessary.

In the event that X-rays are necessary in my case, I understand and agree that X-rays taken in this clinic are the property of Hardick Chiropractic Centre, and will remain in this clinic where they can be reviewed for me by the doctors. I understand that copies can be made available to me, following review with the doctor.

I have indicated an emergency and/or alternate contact with whom this office may communicate, if I can not be contacted personally, or in the case of an emergency. Under such circumstances only, this office has my consent to identify me as a patient to the contacts identified.

I understand and agree that all services rendered are charged directly to me and that I am personally responsible for payment. I understand that fees for professional services are due when rendered. I understand that if I suspend or terminate my care, any fees for professional services rendered will become immediately due and payable.
Do you have health coverage and/or accident insurance?*
- Yes
- No
Your coverage is through

I understand that health and accident insurance policies are an arrangement between an insurance carrier and myself.
Phone
This field is for validation purposes and should be left unchanged.

Save and Continue Later

Health Questionnaire