General Client Information
Please complete these forms prior to your first visit
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Email *
Permission to receive emails (By selecting yes, we can send you appointment reminders and clinic updates) *
What is the First and Last Name? *
Do You Have A Booked Appointment? *
Date of Birth *
Gender *
Address (Street, City, Province, Postal Code) *
Preferred Contact Phone Number *
Cell Phone Number If Different Than Preferred
Family Doctor
Referring Doctor
Why is it important that you get rid of your injury/problem as soon as possible?
What are the TWO main things you would like to achieve by the end of today's session?
How did you find out about us? *
Do You Have Extended Healthcare (Benefits)? *
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