Reactivating Patients

Been a while since you’ve seen us, or maybe your circumstances have changed? Please complete this form to keep us up to date with everything important. If you are a new patient, please complete the new patients form instead.

You are also able to download and print the PDF version of the form, then complete it at home and bring it with you: PDF Reactivating Patients Form

If you prefer, simply arrive 15 minutes early for your appointment and complete the form in our office.

Name(Required)

First Last

Address(Required)

Street Address City State Postcode

Phone (H)(Required)

Phone (M)

Emergency Contact Name

Emergency Contact Phone

Last Chiropractic adjustment at this clinic:(Required)

Day

Month

Year

Have you had any accidents, falls, injuries, etc, since your last visit?(Required)

Yes

No

Please explain your accidents/falls/injuries:(Required)

Have you had a re-occurrence of your former problems?(Required)

Yes

No

What problems are you currently experiencing?(Required)

Do you have any new problems since your last visit?(Required)

Yes

No

Please describe your new problems:(Required)

Have you consulted another doctor for any of the above conditions?(Required)

Yes

No

Which doctor was consulted, and what was the outcome?(Required)

Have you had any illnesses?(Required)

Yes

No

Please describe your illness/es:(Required)

Do you suffer from or have been diagnosed with an allergy?(Required)

Yes

No

Please list your allergies:(Required)

Have you had any surgery?(Required)

Yes

No

Please describe your surgery:(Required)

Is there anything else you want us to know?(Required)

Yes

No

What else do you want us to know?(Required)

Describe the specific areas of your body (including left/right side) where you experience: pain/discomfort, numbness/tingling, loss of function:(Required)

Consent(Required)

I give consent for my treating health professional and/or health providers to disclose any relevant information about my medical conditions and personal information to Farmer Chiropractic and for Farmer Chiropractic to release any of the above mentioned relevant to supporting my care and obtaining payment from any third-party payee. (Please read our privacy statement).

I agree to my information being used as needed

Signature(Required)

Submit

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