NEW PATIENT INTAKE FORM

In order to provide you the best possible care, please complete this form thoroughly. All informaton is strictly CONFIDENTIAL and we comply with Australian privacy laws.

General Information

Your email will NOT be shared with any 3rd parties and is used for occasional office announcements and promotions.
Please briefly explain how you found out about Dr. Greg. For example, "My friend Jane Smith recommended Dr. Greg" or "I did a Google search and found Dr. Greg's website".
*'Third party payor' includes, but is not limited to, WorkSafe, WorkCover, TAC, DVA or Medicare. Before proceeding, please notify reception staff if you intended on using any third party payor scheme to cover the cost of your chiropractic care.

Health Information

SPINAL IMAGING

Bring any spinal images you may have to your first visit.

MEDICATIONS

ALLERGIES

PAST SURGERIES

PAST INJURIES

Consider any broken bones, vehicle accidents, falls, work injuries, birth trauma, sporting injuries, head impact injuries, etc. throughout your lifetime.

BACK PAIN

Enter date if back pain began on a specific date.

NECK PAIN

Enter date if neck pain began on a specific date.

HEADACHES

Enter date if headaches began on a specific date.
Average number of headaches per week over past 3 months.

OTHER PAIN

Enter date if pain began on a specific date.

REVIEW OF SYSTEMS

PAST MEDICAL HISTORY

FAMILY HISTORY

ANY OTHER INFORMATION


PREVIOUS CHIROPRACTIC CARE

EXPLANATION OF SERVICES

Chiropractic is concerned with the relationship between the spinal column and the nervous system as it affects the restoration and maintenance of health; primarily utilising the hands to adjust vertebral subluxations.

These subluxations create interference with the transmission of proper neuro-electrical communication through the spine and extremities. This can cause decreased joint motion, pain, discomfort, and/or a lessening of the body’s ability to function properly. By receiving chiropractic care to correct vertebral subluxation(s), many people experience a pleasant side-effect of relief from pain and discomfort.

Chiropractic care is different to medical treatment. Our primary focus is providing our patients with a pathway towards better health; not the treatment of disease and illness.

Our number one concern is the health and safety of the people we serve. Therefore, we only accept those patients that we determine to have the potential to benefit from our care.


FINANCIAL RESPONSIBILITY

All patients understand and agree that Dr. Greg Kendall | The Wellness Chiropractor does not accept patients seeking care under any third party payor schemes such as, but not limited to, WorkSafe, WorkCover, TAC or Medicare.

All patients acknowledge that they are financially responsible to remit payment in full for all services provided to them.


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< IF PATIENT IS 16 YEARS OR UNDER >

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CONFIRM & SUBMIT FORM

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