File opening – Sicotte DC

Administration

Date

Follow-up

Called

Yes

LM

Imaging

MRI

X-ray

Source

Public

Private

Insurance

Yes

No

Prescription

Call

Need

Have

CD

Call

Have

First Name *

Last Name *

Address *

City *

Postal Code *

Home Phone

Work Phone

Extension

Cell Phone

Email *

Do you authorize the clinic to communicate with you by email? *

Yes

No

Profession

Gender *

Male

Female

Date of Birth *

age

Briefly describe your condition. *

Your objectives

improvement in my quality of life

slowing down the progression of my condition

symptom control

reducing the level of pain

preventing recurrences

reducing medication

avoiding surgery and injections

resolving the herniated disc

returning to sports activities

returning to work

returning to a more active life

facilitating my daily activities

otherother

Do you have recent imaging?

X-ray

CT Scan

MRI

I hereby authorize the chiropractor to perform the examinations he deems necessary for the opening of my file. Some patients may experience aches or slight worsening of symptoms following the exam. These symptoms are generally of short duration, but it is important to mention them to the chiropractor at your next visit. *

Yes

No

Please indicate your preferences for an appointment.

Morning-10:00-13:00

Afternoon-13:30-16:30

Evening-17:00-21:00