New Patients

Confidential Patient Case History

Please fill out the online New Patients form. Mandatory fields are indicated with an *.

New Patients Form Please be advised that all personal information collected on this website will be kept in strict confidence in accordance with provincial and federal laws of Canada and will only be used during regular office procedures. Salutation : Select Miss Mrs. Ms. Mr. * Name: * Address: * City: * Postal Code: * Home Phone:   Format: (613) 555-1234 Business Phone: Ext. Cell Phone: * Date of Birth: Month January February March April May June July August September October November December Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1900 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Email: Gender: Select Male Female Occupation or Profession: Employed By: Marital Status : Select Single Married Divorced Widowed Name of Medical Doctor: Number of Children: Names and Ages: Extended Coverage: No Yes    (Blue Cross, Great West Live, G.S.M.I.P.) Do you currently have a motor vehicle accident claim, for which you are seeking treatment?    No Yes Do you currently have a Workplace Safety and Insurance Board (WSIB) claim, for which you are seeking treatment?    No Yes HEALTH ATTITUDES: Your attitude about your health is as important to us as the specific reason you've consulted our office. Below are four prevalent health attitudes. Please mark the one that most closely refrelcts your personal values. Treatment Only: I only consult a doctor when I have an ache or pain and discontinue care as soon as it has cleared up. Prevention: In addition to symptomatic treatment, I consult specialists occasionally to prevent problems from recurring. Maintaining Health: I'm conscious about my health, diet, excercise, etc. and actively pursue these, because I feel better and it maximizes my potential. Family Health: I take an active part in assisting, informing, and maintaining heath, with my family, and I'm concerned with long term effects of good health. What is your major complaint for which you are seeking Chiropractic care?    Please indicate who told you about our about our office:    Please note that by submitting this form, you agree to one of our staff members contacting you to confirm an appointment via your preferred contact method below Your preferred contact method: Home phone    Business phone    Cell phone    E-mail * Required Fields