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General Client Information
Please complete these forms prior to your first visit
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* Indicates required question
Email
*
Your email
Permission to receive emails (By selecting yes, we can send you appointment reminders and clinic updates)
*
Yes please
No thank you
Required
What is the First and Last Name?
*
Your answer
Do You Have A Booked Appointment?
*
Yes
No, I need one
Date of Birth
*
MM
/
DD
/
YYYY
Gender
*
Male
Female
Prefer not to say
Non-Binary
Required
Address (Street, City, Province, Postal Code)
*
Your answer
Preferred Contact Phone Number
*
Your answer
Cell Phone Number If Different Than Preferred
Your answer
Family Doctor
Your answer
Referring Doctor
Your answer
Why is it important that you get rid of your injury/problem as soon as possible?
Your answer
What are the TWO main things you would like to achieve by the end of today's session?
Your answer
How did you find out about us?
*
Choose
Website
Google
Yellow Pages
Hospital
Family Doctor
Advertising
Insurance Company
Family/Friends
Word of Mouth
Other
Do You Have Extended Healthcare (Benefits)?
*
Yes, my own
Yes, under spouse/parent
No
Required
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