Name
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First Name
Last Name
Date of Birth (DD/MM/YYYY)
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Phone number(s)
*
Email
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Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Do you have children?
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What is your occupation?
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Are you covered by Private Health Insurance?
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Do you have a pension/DVA/health care card?
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If yes, expiry:
Is your condition covered under Work Cover or Motor Vehicle Accident (Third Party)?
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Do you have a referral from your GP for an Allied Health Plan?
(Also referred to as a Team Care Arrangement (TCA) or Enhanced Primary Care (EPC) Plan)
Have you previously received chiropractic care?
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Have you received any other treatment for this condition?
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If yes, please describe:
How would you describe your response to this treatment?
Are you currently pregnant? If yes, how many weeks?
We would appreciate your assistance in helping us to ascertain your current level of health - have you currently or previously been diagnosed with any of the following:
Does anyone in your family experience any of the above?
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If yes, please provide details:
Are you currently taking any medication? If yes, please include details:
Have you ever been in a car or motor bike accident? If yes, please tell us when it occurred and describe:
Please list and describe (including dates) any other accidents, falls, fractures or previous operations:
Have you had any scans or x-rays taken that might be relevant? If yes, please provide details below and bring them to your initial appointment if possible:
What were the scans of, when were they taken and where:
Emergency/alternative contact name:
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First Name
Last Name
Emergency/alternative contact phone number:
*
What is their relation to you:
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Did someone refer you to our Clinic? If yes, what is their name and relation to you?
By clicking submit, I confirm that the personal information provided is true and correct. I acknowledge that it will be treated with confidentiality according to Victor Harbor Chiropractic's privacy policy.
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Thank you, we have received your patient intake form and we look forward to seeing you at your appointment. If you have not booked an appointment, please call us on 8552 3511 to arrange a time. Please contact us if you have any questions regarding your initial appointment.
