New File: Admission form
In accordance with the rules of the Ordre des Chiropraticiens du Québec, all patients must complete this opening file before their first consultation.
General Information
First Name *
Your answer
Last Name *
Your answer
Gender *
Birthday *
MM
/
DD
/
YYYY
Home phone *
Your answer
Mobile phone *
Your answer
Email address *
Your answer
Street # and name *
Your answer
City *
Your answer
Postal Code *
Your answer
Province *
How did you find out about our clinic? *
If you were referred by someone, please let us know who so that we may thank them: *
Your answer
Do you authorize the clinic to contact you by e-mail? *
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