VWC Consult Form
Before we accept you as a patient we first need to see if we can help you. Your responses will determine if you qualify for treatment in our office. Please be as thorough as possible in each response to the questions asked.
Date of Birth
Best Phone # to reach you
Who may we thank for referring you?
Please provide the person's name who referred you or the online source that directed you to our practice.
Reason for seeking treatment?
Please describe in detail what you know to be going on with your condition.
What have you tried before?
How & when did it originally start?
What makes it better?
What makes it worse?
Describe the quality of your complaint
Does it radiate anywhere?
Severity of Issue
Not so bad
Timing of your problem
25% of the time
50% of the time
75% of the time
100% of the time
Please provide us with an explanation of why you would qualify to be treated in our office
We only choose to work with those who are truly committed to getting better. This means that you're willing to follow and adhere strictly to the recommendations we give.
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