First Day Form ... Welcome!
NAME *
Your answer
Address, Town, Zip *
Your answer
Phone *
Your answer
Email *
Your answer
Why do you feel you need chiropractic adjustments? *
Your answer
Are you nervous or comfortable with the idea of having your spine and nervous system? *
Have you ever been adjusted by a chiropractor before? *
Required
Anything else you want Dr. Rick to know about you or your health or anything? *
Your answer
How often do you think you feel comfortable coming for adjustments? *
Required
Is there anyone else in your family, like spouses or children or parents that should come to the chiropractor also? *
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